IPV Use Expands to More Patients

IPV Use Expands to More Patients

By Margaret Varnell, RN, RRT

Intrapulmonary Percussive Ventilation (IPV), the therapeutic modality developed by Forest Bird, MD, PhD, Sc., is being used for more than cystic fibrosis patients these days. In fact, it can be used for almost any patient having difficulty with secretions. Studies increasingly show IPV results in increased sputum production, improved breath sounds, improved gas distribution, improved lung and chest wall mechanics, resolution of lung infiltrates and atelectasis, and decreased ventilator hours.

Put very simply, IPV is a form of CPT given internally with a bonus. It also delivers a high-density aerosol to hydrate sticky dry secretions and incorporates Positive Expiratory Pressure (PEP) therapy to help mobilize those secretions. In other words, it wets down the secretions, shakes them up and pushes them out.

In delivery, it resembles IPPB. The patient breathes through a mouthpiece and receives a deep breath. The difference is in the way the breath is delivered. During the IPV breath, the patient receives short, high flow bursts (or pulses) of gas. These are short breaths stacked on top of each other until they reach a volume equal to one deep breath. It is sometimes described as a stair-stepped IPPB treatment.

IPV is pneumatically driven and works on pressure rather than volume. As the patient becomes more accustomed to the way the breath feels, he can adjust the source pressure. What this does is deliver the little breaths faster. Instead of taking 10 steps to get to one big breath, the equipment can be adjusted to deliver 15-20. The process shakes up the lungs a little more, causing more secretions.

TWO PHASES

For all you techno freaks in the audience, IPV inhalation can be broken down for discussion purposes into two phases: percussion and the percussion interval.

The percussion is the actual bursts themselves; the percussion interval is the time in between the bursts. The machine cycles sound like “bump, bump, bump.” The bump is the burst or percussion and the time in between is the percussion interval. The percussion (bursts of gas) cycles at a rate of over 200 pulses per minute. Don’t get confused here. The patient is not breathing over 200 times a minute but is receiving over 200 pulses of flow in a single breath. The actual breathing rate is usually within normal limits of 8-20 bpm.

In addition to shaking the lungs, the gas flow creates and maintains a form of CPAP that holds the airway open. This is known as the intrapulmonary wedge pressure. The bursts of gas create vibrations that resonate throughout the entire tracheobronchial tree and help mobilize secretions.

This internal vibration is the same mechanism that the PEP and Flutter devices use to mobilize secretions. The limitation of PEP and Flutter is that it is patient-dependent. IPV, however, because it is powered by an external gas flow, can incorporate an aerosol delivery as well. It is recommended that aerosol used incorporate both vasoconstrictor (alpha) and bronchodilator (beta). Racemic Epinephrine (2.25) well diluted with normal saline is the aerosol most widely used.

VENTILATOR INTERFACE

IPV can be used in association with continuous ventilation. A ventilator interface has been developed. It is as easy as introducing a connector to the inspiratory side of the breathing circuit.

The connector has a one-way valve and a pressure relief valve for safety. The connector attaches to a valve called the IPV Phasitron. This valve attaches and regulates the IPV nebulizer.

It sounds complicated, but it really isn’t that bad. Now you may be concerned about adding the extra pressure to the patient’s lungs. Used properly, the IPV therapy does not contribute to barotrauma. A commonly used protocol is to determine the patient’s average PIP over the last eight hours and set the ventilator high-pressure limit 10 cm above that number. So the ventilator is still sensing at the patient wye and it cycles off when its pressure limit is reached.

Adjusting the ventilator tidal volumes and flow rates are also important for optimum and safe use, but these are more patient-specific and cannot be generalized into a standing protocol. Studies are reporting resolution of infiltrates and atelectasis as well as improved weaning for many ventilator patients using IPV.

Margaret Varnell, New Orleans, is a practitioner and freelance writer.

Case Studies Reflect Care in Small Facility

By Margaret Varnell, RN, RRT

Hardy Wilson Memorial Hospital is a 49-bed acute care facility in Hazelhurst, Miss., about 30 miles south of Jackson. The respiratory therapy department provides fairly general care. Staff do the routine floor treatments, oxygen therapy and ventilator management you would expect. It would be easy to categorize Hardy Wilson as a backwards, rural hospital. Except it is not.

Staff in this rural facility use point-of-care ABG analyzers, therapist-driven protocols, and a host of up-to date techniques that put many larger institutions to shame. Therapists are well educated, keep up with changing technologies and are confident enough in their skills to speak up on behalf of their patients.

They do not demand their competency be noticed. They quietly demonstrate it. Therapists are respected and supported by the medical staff.

Among the treatment modalities they use are BiPAP, PEP, and IPV. They started using IPV in March 1997.

“I first heard about IPV from a journal article” said Kathy Nichols, RRT, department manager. “Our medical director, Ken Whittington, MD, ordered it for a patient on the very first day we had the unit, and we have used it routinely ever since.”

Among users are those with far different needs.

CASE STUDY #1

Harry is a 72-year-old COPD and CHF patient who is well known to the staff at Hardy Wilson. He had been admitted for respiratory failure and intubated on previous admissions before being treated with IPV. He receives home oxygen and therapy and averages a hospital admission every three months.

Harry arrived in the ER at Hardy Wilson complaining of SOB and weakness during ambulation. He was admitted and started on hand-held nebulizer treatments. There was little or no improvement during the first 24 hours so staff started him on IPV. By day two of IPV, his chest X-ray showed improvement and his ABGs were improving. He was up and walking on day three and discharged the next day. His length of stay over previous admissions was decreased by 48 hours.

CASE STUDY #2

Betty is another Hardy Wilson patient who reflects IPV’s effectiveness. She is a 42-year-old asthma patient who experiences recurrent fungal infections. She was admitted to the hospital with bilateral infiltrates. She was started on IPV q 4 around the clock. Within 36 hours, her infiltrates had cleared an estimated 50 percent, her breath sounds had improved, and she was more comfortable. Her length of stay was three days. On her prior admission for the same circumstances, her length of stay had been seven days.

These cases are by no means hard scientific proof. But they don’t necessarily need to be. Rural hospitals are faced with the challenge of providing care to a diverse group of people. Many of their patients farm and work in factory settings and are exposed dust, fumes, bacteria and fungi.

By the time they get to the hospital they are extremely ill. IPV and other modalities are important to them. The new modalities available allow the respiratory staff to intervene and make a difference in the health care and quality of life of rural patients.

In these smaller facilities, RCPs know their patients by name, know the details of their conditions, and see them in the grocery stores. It is easy for staff in larger institutions to turn up their noses and scoff at care provided in a smaller hospital.

But Hardy Wilson is an example of respiratory care making a difference. It is an example of American health care at its best.

Margaret Varnell, New Orleans, is a practitioner and freelance writer.

My Experience with

IPV

By Kathy Nichols, RRT

OLD COUPLE

Sept. 30, 1997, was a busy day. I knew I was coming down with something, but I had patients to see and things to do so I proceeded as normal. I was really feeling bad by the end of the shift so I decided to go to the ER and get a prescription…or a shot in event of a worse case scenario. I had no idea my day was about to become longer.

In the ER, I had a bronchospasm. It was the most frightening thing I have ever experienced in my life. As a therapist, I kept thinking, “I am going to code right here in front of everybody” As a patient, I thought, “God, help me! I can’t breathe!”

I was terrified. I really thought I was going to die. I was lucky though that a physician and staff were in the room when it happened, and they responded fast. My bronchospasm broke with treatment and I was admitted with bilateral pneumonia to our acute care floor.

My initial chest X-ray was ugly. I had bilateral patchy infiltrates, enlarged vasculature, left lingula and right middle lobe pneumonia. It was just overall awful. Clinically speaking, the X-ray correlated perfectly to how I looked and felt.

After I was stabilized, I was moved to my room and started on 125 mg IV Solumedrol q 8, 1 gram Rocephin q 24 x 3, and IPV with albuterol q 4 hours. I wasn’t surprised by the IPV order. It was our policy, and I was the perfect candidate. I knew our doctors and staff knew what they were doing.

FEAR AND EXHAUSTION

But I was afraid of the IPV! After my near code experience, I was exhausted and in a great deal of pain from coughing. I was afraid the IPV might increase the pain in my chest. But the therapist side of me kicked in at that point. I knew IPV was exactly what I needed to get well quickly. I told myself that it would help loosen the consolidated secretions and allow more room for oxygenation, which I dearly needed. My SaO2 levels were in the 80s at this time and I was on 2 lpm nasal cannula.

Even though my first treatment was a bit rough, I don’t think I gave the practitioner a hard time. But I was coughing a lot and bringing up a lot of sputum. About an hour after the treatment, I realized that I was feeling better. I was breathing easier, and coughing less.

Wednesday, Oct. 1, was a little better. After 24 hours of therapy, I was breathing easier and starting to rest. My breath sounds had improved from bilateral rhonchi and diffuse wheezing to only faint scattered expiratory wheezing. My cough was still productive, but I was coughing about 75 percent less. Overall I felt great after just 36 hours of care.

By Friday morning, my chest X-ray was completely clear and I was discharged. I was still on antibiotics and instructed to rest (at least until Monday). My hospital stay had been 2.5 days. I attribute my rapid recovery to the IPV therapy and the effective way it helped clear my consolidated pneumonia. I also am grateful for the wonderful care I received from my doctors, nurses and, of course, my own respiratory care staff.

From first hand experience I can truly say that I know IPV works. As bad as I felt at the time, I think my bout with pneumonia was a valuable experience. I can confidently recommend this treatment. Now when my patients with pneumonia tell me how bad they feel, I honestly know.

Kathy Nichols is the director of respiratory care at Hardy Wilson Memorial Hospital, Hazlehurst, Miss.