LUNG VOLUME RECRUITMENT – MANUAL AND
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1. MMLVR see Appendix A1 3 Assemble and test the equipment see Appendix A3 4 Explain the procedure to the client 5 Establish with the client the signal they will use to indicate when MIC is reached or they wish to stop 6 Ask the client to take a deep breath and hold it apply the mask mouthpiece and ask the client to continue to inhale 6 1 If using a mouthpiece ask the client to place their lips tightly around the mouthpiece to prevent an air leak You may need to use a nose clip initially until the client is proficient with MMLVR 6 2 If using a mask have the client hold the mask firmly on their face to prevent air leak If client is unable to hold the mask on their face a caregiver will hold the mask on the face 6 3 If performing MMLVR through a tracheostomy tube ensure the client has a cuff less tube or that the cuff is deflated Note If the client tolerates corking it is preferable to cork the patient and perform procedure through the upper airway 7 Cue client to inhale again to stack breaths Squeeze bag in synchrony with client s inhalation Client must not exhale between each breath Continue to stack breaths CAREWEST Care and Service Manual V Ca rewest Section CCL INNOVATIVE HEALTH CARE Subsection Respiratory Care LUNG VOLUME RECRUITMENT CS 04 03 13 Page 4 of 16 MANUAL AND MECHANICAL three to five times as tolerated by client Note The client may feel a stretch in the chest o2. bronchospasm incontinence e muscular damage or discomfort fatigue cough paroxysms rib or costochondral junction fracture chest pain Contraindications to Abdominal Assisted Cough Pregnancy Hiatal Hernia Abdominal aortic aneurysm Open Abdomen Recent abdominal surgery Abdominal anomaly Acute upper gastrointestinal bleed Paralytic Ileus Precaution to Abdominal Assisted Cough TVC Filter Insertion of new abdominal feeding tube lt 48hours Technique 1 SS Similar to the Heimlich Maneuver Client Position Supine or sitting with Head of Bed HOB at desired angle Assister Hand Position Standing beside client or straddling client place heel of 1 hand over abdomen midline 2 below bottom of breast bone place second hand on top and interlock fingers Action Client takes deep breath and tries to cough Assister at beginning of cough pushes in and up evenly firmly and quickly CAREWEST Care and Service Manual V Ca rewest Section CCL INNOVATIVE HEALTH CARE Subsection Respiratory Care LUNG VOLUME RECRUITMENT CS 04 03 13 Page 7 of 16 MANUAL AND MECHANICAL Technique 2 Forearm and Hand Client Position Supine or sitting with HOB at desired angle Assister Hand Position Standing beside client and place upper arm s forearm across upper chest and lower hand over abdomen fingers facing client s chin Action Client takes deep breath and tries to cough
3. 4 Set the inhalation and exhalation pressures see Appendix B4 5 Start with the pressure to 20 30 cmH2O this will familiarize the client with the feel of mechanical insufflation exsufflation 6 Adjust pressures as required to meet client needs and tolerance Procedure performed with a mouthpiece or mask 7 Verify pressure settings before starting each treatment Note As this machine provides positive pressure all the risks associated with positive pressure ventilation apply to this therapy 8 Attach the appropriate client interface to the breathing circuit Note a full facemask is the preferred interface 9 Apply the interface to the client 10 Instruct the client to inhale while shifting the manual control lever to the inhale position and hold for 2 to 3 seconds count time out loud 11 Rapidly shift the manual control lever to the exhale position to induce a cough holding it there for 1 to 2 seconds Note encourage the client to cough on exhalation phase A manual assisted cough maneuver may be added where indicated at the onset of exhalation Count time out loud 12 Repeat this inhale exhale cycle 4 to 5 times as tolerated by the client Note Allow the client to rest for 20 to 30 seconds after each cycle of 4 to 5 breaths 13 Tf the client coughs up secretions during any of the inhale exhale cycles remove the interface and clear the secretions before initiating any additional cycles CAREWEST Care a
4. Indications and Contraindications of LVR MI E 6 LVR will only be performed on patients clients who are alert cooperative and able to communicate fs LVR is most effective when performed in conjunction with appropriate chest therapy 8 When performed through a tracheostomy LVR MI E may lead to obstruction of tracheostomy tube Caution should be exercised when performing LVR MI E with an artificial airway Post procedure assessment of tracheostomy tube patency is vital 9 To avoid hyperventilation do not perform LVR procedures more frequently than every 10 minutes 10 LVR can be performed in conjunction with an assisted cough maneuver see Appendix A2 CAREWEST Care and Service Manual V Ca rewest Section CCL INNOVATIVE HEALTH CARE Subsection Respiratory Care LUNG VOLUME RECRUITMENT CS 04 03 13 Page 3 of 16 MANUAL AND MECHANICAL APPENDIX A Lung Volume Recruitment MMLVR EQUIPMENT 1 disposable Bagging Unit reservoir removed and oxygen tubing removed clearly labeled Not for CPR 1 set of nose clips optional 2 one way valve connectors remove leaf valve from device closest to client 1 connector 4 pieces of 6 inch corrugated tubing 1 mouthpiece mask or tracheostomy 15mm adaptor PROCEDURE 1 Verify Physician s order Note the initial order will be directed to RRT and or PT as an LVR Manual and Mechanical Assess and Treat order 2 Determine client eligibility for LVR
5. Assister at beginning of cough pushes down with forearm and in and up with lower hand evenly firmly and quickly Technique 3 Hands on lateral ribs Client Position Supine or sitting with HOB at desired angle Assister Hand Position Standing beside client place hands on side of client s lower rib cage Action Client takes deep breath and tries to cough Assister at beginning of cough pushes hands down and in firmly and quickly Appendix A3 How to Obtain Modified Bagging Unit CAREWEST Care and Service Manual V Ca rewest Section CCL INNOVATIVE HEALTH CARE Subsection Respiratory Care LUNG VOLUME RECRUITMENT CS 04 03 13 Page 8 of 16 MANUAL AND MECHANICAL Appendix A4 Cleaning Assembly Testing of Equipment used for MMLVR This procedure is completed on a weekly basis Cleaning 1 Mouthpiece Mask Corrugated Tubing One Way Valves and Nose Clips Clean with warm soapy water rinse well and allow to air dry 2 Bagging Unit Clean exterior with damp cloth Interior of bagging unit should remain clean as one way valve isolates bagging unit from client Testing of Equipment The bagging unit should be tested prior to each use to ensure alignment of the 1 way valve and proper functioning of the unit To test the unit 1 Occlude client connector of bagging unit squeeze bagging unit resistance should be felt no air should leak from bagging unit 2 With client connector of bagging unit
6. W Carewest INNOVATIVE HEALTH CARE LUNG VOLUME RECRUITMENT MANUAL AND MECHANICAL Related terms Modified Manual Lung Volume Recruitment MMLVR and Mechanical Insufflation Exsufflation MI E Authorized by Clinical Directors RATIONALE Section CCL Subsection Respiratory Care CS 04 03 13 Page 1 of 16 Date Established Dates Revised June 2012 Date For Review June 2015 To provide guidelines for the safe and effective use of Lung Volume Recruitment LVR including Modified Manual Lung Volume Recruitment MMLVR and Mechanical Insufflation Exsufflation MI E APPLICABILITY RN LPN RRT PT DEFINITIONS Assisted Cough Maneuver The application of a rapid abdominal thrust or lateral costal compression using various hand placements after an adequate spontaneous inspiration or maximal insufflation Also known as a quad cough see Appendix A2 for procedure indications contraindications and complications Glossopharyngeal A method of breathing which consists of a stroke like Breathing GPB action of the tongue along with constricting action of the pharynx pumping air through the larynx into the lungs Maximum Forced The maximum flow rate measure during a forced vital Expiratory Flow MaXrrr capacity VC maneuver Maximum Insufflation The maximum volume of air stacked within the client s Capacity MIC lungs beyond spontaneous vital capacity MIC is obtained by having the take a
7. d restore cuff inflation to pre treatment state if applicable CAREWEST Care and Service Manual V Ca rewest Section CCL INNOVATIVE HEALTH CARE Subsection Respiratory Care LUNG VOLUME RECRUITMENT CS 04 03 13 Page 13 of 16 MANUAL AND MECHANICAL Appendix B1 Indications and Lung Volume Recruitment MI E 1 Clinical Indications a A client who is alert cooperative and able to communicate and i has an established diagnosis of a neuromuscular or mechanical disorder that limits thoracic expansion including but not limited to spinal cord injuries amyotrophic lateral sclerosis ALS muscular dystrophy progressive multiple sclerosis MS Guillain Barr syndrome GBS post polio syndrome syringomyelia and kyphoscoliosis ii may be unable to mobilize and expectorate secretions iii has a VC less than 70 predicted or anticipate a continued decline in VC 2 Absolute Contraindications a hemoptysis b untreated or recent pneumothorax bullous emphysema severe COPD c asthma d recent cardio thoracic surgery e increased intracranial pressure ICP f intracranial drains g nausea h impaired consciousness inability to communicate 3 Relative Contraindications a immediately following meals b rib fractures c hemodynamic instability d pregnancy e history of pneumothorax f presence of a large pleural effusion g client unable to breath stack 4 Precautions a Clients known to have card
8. deep breath holding it and then breath stacking using a MMLVR bagging unit Peak Cough Flow PCF The velocity of air expelled from the lungs after a cough CAREWEST Care and Service Manual V Ca rewest Section CCL INNOVATIVE HEALTH CARE Subsection Respiratory Care LUNG VOLUME RECRUITMENT CS 04 03 13 Page 2 of 16 MANUAL AND MECHANICAL maneuver as measured by a peak flow meter A minimum PCF of 160 L min is required for effective secretion removal PCF can be measure using a simple peak flowmeter or calculated by multiplying the Forced Expiratory Flow FEF X 60 Vital Capacity VC The maximum amount of air that can be exhaled after a maximum inhalation POLICY l MMLVR and MI E will only be performed by designated staff who have undergone approved education and training 2 A physician s order is required to perform LVR MMLVR and MI E 3 LVR MMLVR and MI E cannot be performed through an endotracheal tube 4 LVR MMLVR is used for the purpose of improving vital capacity VC and peak expiratory cough flow PCF in clients with impaired respiratory function Please see Appendix A1 for Indications and Contraindications of LVR MMLVR 5 LVR MI E is used for the purpose of assisting the removal of retained secretions in clients with impaired secretion clearance and ineffective cough including but not limited to spinal cord injury neuromuscular disease and syringomyelia Please see Appendix B for
9. eviously using LVR MMLVR treatments should continue on a daily basis minimum twice a day This ensures the client will be able to resume LVR MMLVR once the LVR MI E is discontinued e Clients requiring supplemental oxygen can be oxygenated between MI E treatments EQUIPMENT 1 Mechanical Insufflator Exsufflator 1 5 foot large bore disposable tubing 10 6 inch pieces of corrugated tubing with 15 mm connector for tracheostomy clients CAREWEST Care and Service Manual V Ca rewest Section CCL INNOVATIVE HEALTH CARE Subsection Respiratory Care LUNG VOLUME RECRUITMENT CS 04 03 13 Page 11 of 16 MANUAL AND MECHANICAL l bacteria filter 1 transparent resuscitation mask or 1 tracheostomy tube connector or 1 mouthpiece and nose clip used if client does not tolerate mask 1 suction source with Yankauer or tracheal suction catheter consider use of in line catheter PROCEDURE 1 Verify Physician s order Note the initial order will be directed to RT and or PT as an MI E Assess and Treat order 1 1 Determine client s eligibility for MI E see Appendix B1 1 2 Explain the procedure to the client 2 Set up equipment see Appendix B2 2 1 Attach Yankauer or suction catheter to suction 2 2 Attach the breathing circuit to the MI E machine 2 3 If you have an automatic machine place the machine on manual mode 3 Ensure MI E machine is cycling and returning to neutral see Appendix B3
10. iac instability should be monitored for arrhythmias SpO2 dyspnea vital signs and symptoms b Patients clients with long standing thoracic cage restriction who may have severely reduced thoracic compliance will require low incremental insufflations during the initial MI E introductory period CAREWEST Care and Service Manual V Ca rewest Section CCL INNOVATIVE HEALTH CARE Subsection Respiratory Care LUNG VOLUME RECRUITMENT CS 04 03 13 Page 14 of 16 MANUAL AND MECHANICAL APPENDIX B2 Initial Set Up for MI E Plug machine into electrical outlet Position the unit within easy reach of the client or the operator of the unit CAUTION Position the device so that the air intake ports on the side and rear of the unit are not blocked ce Assemble the client circuit filter large bore tubing and client interface as follows a Attach the bacterial viral filter to the client port on the front of panel b Attach the 5 foot 22mm ID large bore tubing to the bacterial viral filter c Attach the appropriate client interface to the large bore tubing Ne CAREWEST Care and Service Manual V Ca rewest Section CCL INNOVATIVE HEALTH CARE Subsection Respiratory Care LUNG VOLUME RECRUITMENT CS 04 03 13 Page 15 of 16 MANUAL AND MECHANICAL APPENDIX B3 Operational Verification Attach client circuit to the unit and block the end of the hose Turn the power switch ON Set the manual auto switch to manual position aut
11. ired at family caregiver discharge and obtain MD prescription CAREWEST Care and Service Manual V Ca rewest Section CCL INNOVATIVE HEALTH CARE Subsection Respiratory Care LUNG VOLUME RECRUITMENT CS 04 03 13 Page 10 of 16 MANUAL AND MECHANICAL APPENDIX B Lung Volume Recruitment MI E Points of Emphasis MI E e LVR MI E is best performed in the sitting or semi recumbent position however it can be done in the supine position if required e Cervical spine stabilization must be assessed and the head and neck must always be supported if an assisted cough maneuver is performed in conjunction with exsufflation e A jaw thrust may be required to maintain airway patency in clients with significant bulbar muscle weakness e LVR MI E sessions are performed as per assessed need to a maximum of every 10 minutes to avoid hyperventilation e LVR MI E is ideally done in the morning upon awakening before meals and at bedtime e Inspiratory and expiratory pressures of 20 to 30 cmH20 can be used to start If the secretions are not being mobilized increase the amount of expiratory pressure until they are cleared Incremental changes of 5 cmH20 can be tried Minimum effective pressures are usually 30 cmH20 with the most clinical effective pressures being 40 to a maximum of 50 cmH20 e Insufflation exsufflation pressures are usually the same unless one wishes to minimize stretch to the intercostals muscles e For clients pr
12. nd Service Manual V Ca rewest Section CCL INNOVATIVE HEALTH CARE Subsection Respiratory Care LUNG VOLUME RECRUITMENT CS 04 03 13 Page 12 of 16 MANUAL AND MECHANICAL 14 The entire procedure 4 to 5 inhale exhale cycles can be repeated 4 to 6 times during a treatment session 15 No oxygen is to be entrained into the MI E machine clients requiring high levels of oxygen may require pre oxygenation or may require re oxygenation between cycles Note oxygen can not be entrained into the circuit as this is a fire risk Procedure performed through a Tracheostomy T7 Assemble 10 six inch pieces of corrugated tubing with 15 mm ID connectors 8 Attach flex tubing to machine and then to the client 9 Perform the inhale exhale cycles as with a mouthpiece or mask 10 Tf flex tube fills with secretions discard it and replace with new 6 inch flex tube 15 mm ID connector may need to use higher pressures due to reduced diameter of the artificial airways 11 A cuffed tube is preferred and should be inflated when performing the in exsufflation The inexsufflator is connected directly to the tracheostomy tube 12 In exsufflation may be delivered on a client with a cuffless tracheostomy tube Cork the tube and apply the in exsufflation via a mouth piece or mask The client must tolerate corking for the procedure and have excellent control of the upper airway 13 Ensure to check the patency of the tracheostomy tube post procedure an
13. omatic models only Set the pressure knob fully clockwise maximum pressure Cycle the manual control lever from inhale to exhale and observe the pressure gauge to ensure that positive and negative pressure is being applied to the patient circuit 6 Release the manual control lever from inhale position and observe that the pressure immediately drops to 0 cm H20 Repeat for the exhale position In either case if the pressure does not drop to zero the unit should not be used AG len APPENDIX B4 Setting and Adjusting the Insufflation Exsufflation Pressures l Turn on the power switch 2 Set the air flow to full 3 Attach the client circuit to the unit and block the end of the breathing circuit 4 Set the manual auto switch to manual automatic models only 5 Slide the manual control lever to the exhalation phase to the left Observe the pressure gauge on the unit and adjust the maximum pressure negative using the pressure knob to achieve the correct reading on the gauge 6 Shift the manual control lever to the inhalation phase slide to the right Adjust the pressure reading by turning the inhale pressure knob to achieve the correct reading on the pressure gauge clockwise to increase pressure and counterclockwise to decrease pressure T7 Cycle the manual control lever from inhale positive to exhale negative and back a few times to ensure that the pressure and suction readings are correct 8 Release the manual c
14. ontrol lever to ensure that the pressure immediately returns to 0 cm H20 If it does not do not use the unit and send for maintenance 9 Inspiratory and expiratory pressures of 20 to 30 cmH20 can be used to start If the secretions are not being mobilized increase the amount of expiratory pressure until they are cleared Incremental changes of 5 cmH20 can be tried Minimum effective pressures are usually 30 cmH20 with the most clinical effective pressures being 40 to a maximum of 50 cmH2O Insufflation exsufflation pressures are usually the same unless one wishes to minimize stretch to the intercostals muscles CAREWEST Care and Service Manual V Ca rewest Section CCL INNOVATIVE HEALTH CARE Subsection Respiratory Care LUNG VOLUME RECRUITMENT CS 04 03 13 Page 16 of 16 MANUAL AND MECHANICAL REFERENCES Calgary Health Region May 2008 Lung Volume Recruitment Manual and Mechanical CLINC 103 Respiratory Services CAREWEST Care and Service Manual
15. open squeeze the bagging unit the bagging unit should re inflate quickly Assembly 1 Reassemble the unit by connecting the corrugated tubing to the client connector place one way valves in line and then connect mouth piece See picture in Appendix A3 CAREWEST Care and Service Manual V Ca rewest Section CCL INNOVATIVE HEALTH CARE Subsection Respiratory Care LUNG VOLUME RECRUITMENT CS 04 03 13 Page 9 of 16 MANUAL AND MECHANICAL Appendix A7 Community Modified Manual Lung Volume Recruitment Algorithm MD orders RT PR MMLVR Assess and Treat Community RRT PT consults MD VC Vital Capacity LVR Lung Volume Recruitment MI E Mechanical MD orders RRT PT In Exsufflator MMLVR Assess and Treat Any relative or absolute YES contraindications Contact MD Measure VC if available and client is able MD overrides Spont VC lt 70 or contraindications client unable to mobilize secretions or expected to decline YES NO Trial of MMLVR Continue current management Notify MD do not start MMLVR Improved secretion mobilization improved cough strength Client tolerating procedure Trial MMLVR with manual cough assist Continue MMLVR Do not continue Teach technique to family caregiver without manual cough MMLVR Consider trial of MI E if above assist Notify consulting procedure is ineffective Arrange for Teach technique to physician continuing follow up if requ
16. r slight discomfort when MIC is reached 8 Once the client s lungs are full or the client signals MIC is reached remove the mouthpiece mask or connector from the client and ask the client to continue holding their breath for 3 to 5 seconds and then slowly exhale 8 1 If secretions are present instead of slowly exhaling ask the client to produce a strong cough huff or include an assisted cough maneuver when indicated See Appendix A2 9 Repeat steps 6 thru 8 three to five times CAREWEST Care and Service Manual V Ca rewest Section CCL INNOVATIVE HEALTH CARE Subsection Respiratory Care LUNG VOLUME RECRUITMENT CS 04 03 13 Page 5 of 16 MANUAL AND MECHANICAL Appendix A1 Indications and Contraindications for LVR MMLVR 1 Clinical Indications A client who is alert cooperative and able to communicate and a has an established diagnosis of a neuromuscular or mechanical disorder that limits thoracic expansion including but not limited to spinal cord injuries amyotrophic lateral sclerosis ALS muscular dystrophy progressive multiple sclerosis MS Guillain Barr syndrome GBS post polio syndrome syringomyelia and kyphoscoliosis may be unable to mobilize and expectorate secretions c has a VC less than 70 predicted or anticipate a continued decline in VC 2 Absolute Contraindications a hemoptysis b untreated or recent pneumothorax bullous emphysema severe COPD c asthma d recen
17. t cardio thoracic surgery e increased intracranial pressure ICP f intracranial drains g nausea h impaired consciousness inability to communicate 3 Relative Contraindications a immediately following meals b rib fractures c hemodynamic instability d pregnancy e history of pneumothorax f presence of a large pleural effusion g client unable to breath stack 4 Precautions a Clients known to have cardiac instability should be monitored for arrhythmias SpO2 dyspnea vital signs and symptoms b Clients with long standing thoracic cage restriction who may have severely reduced thoracic compliance will require slow incremental insufflations during the initial MMLVR introductory period CAREWEST Care and Service Manual V Ca rewest Section CCL INNOVATIVE HEALTH CARE Subsection Respiratory Care LUNG VOLUME RECRUITMENT CS 04 03 13 Page 6 of 16 MANUAL AND MECHANICAL Appendix A2 Assisted Cough Maneuver Indication is to aid client with weak and or paralyzed muscles to clear secretions Assess strength of cough to decide on the amount of assistance and technique required for an effective cough Contraindications to Lateral Costal Technique 3 and Forearm Assisted Cough osteoporosis ribs spine kyphoscoliosis e rib thoracic pathology such as fractures bruising and metastasis Complications of Assisted Cough Maneuver reduced coronary perfusion headache regurgitation
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