Intermittent Positive Pressure Breathing (IPPB) Guideline for Practice 2015

Version: This replaces the IPPB Guideline for Practice, September 2012
Review Date: September 2015
Contact: Regan Bushell, Senior Physiotherapist, 07812269729 or Eleanor Douglas
Lecturer/Practitioner Physiotherapist. Ext: 56142

Disclaimer
This guideline has been registered with the Nottingham University Hospitals Trust. However,
clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will
remain the responsibility of the individual clinician. If in any doubt regarding this procedure,
contact a senior colleague. Caution is advised when using guidelines after the review date.
Please contact the named above with any comments/feedback.

Introduction

This guideline describes the procedure for the use of Intermittent Positive Pressure Breathing
(IPPB) for the purposes of physiotherapy treatment in adult patients. IPPB is a technique used to
provide short- term or intermittent mechanical ventilation for the purpose of augmenting lung
expansion or assisting ventilation. IPPB uses a pressure-limited ventilator that applies a positive
inspiratory pressure, which is triggered by the patients spontaneous effort.

Indications For Use

IPPB has been shown to increase Tidal Volume (VT) and Minute Ventilation (MV), therefore the
rate of alveolar ventilation. This can have the effect of improving Pa02 levels and reducing PaC02.
The application of the positive pressure reduces the work of breathing associated with inspiration.
IPPB may be of value in the following situations:
1. To augment VT in the presence of hypoventilation due to weakness, fatigue or diminished
level of consciousness.
2. Assisting secretion clearance where pathology or fatigue limits the ability to cough or
ventilate effectively

N.B. Used in isolation, IPPB will have no effect on functional residual capacity (FRC)

Contraindications

Undrained Pneumothorax (or suspected by the presence of surgical emphysema) is an absolute

contraindication to IPPB

Intermittent positive pressure breathing (IPPB) Guideline 2015 1

Precautions (Discuss with Specialist Registrar /Consultant prior to use)

Maxfax surgery where an oral flap is used

Facial fractures
Unprotected brain aneurysm (Mr G Dow patients only at QMC campus)
Recent oesophageal, pulmonary or anti-reflux surgery
Gastric distention with no ng in situ
Cardiovascular System Instability (hypotension and arrhythmias)
Raised ICP
Uncontrolled pain
Nausea
Bronchospasm
Pulmonary oedema
Extreme tachypnoea
Large airway carcinoma
Emphysematous bullae and/or evidence if intrinsic PEEP
Unexplained heamoptysis
Self -ventilating patients with a known hypoxic drive (if 02 machine is to be used)

Complications

Air swallowing (particularly problematic if it occurs in anti-reflux surgery patients)

Hypotension due to positive pressure reducing venous return
Patient intolerance
Pneumothorax and lung injury may occur in any patient with indiscriminate and uncontrolled use
of IPPB

Intermittent positive pressure breathing (IPPB) Guideline 2015 2

Guideline for Practice

Action Rationale

Gain consent from the patient and explain the effects of IPPB Confirms the patient is willing to
undertake the treatment
Prepare the patient by ensuring analgesia and information is Minimises patient discomfort,
given as required thereby maximising the
effectiveness of the procedure
Position the patient according to assessment findings and Maximise effectiveness of
treatment aims procedure by optimising gas
distribution
Select interface: full facemask or mouthpiece (a nose clip may To ensure appropriate patient
be required) or via tracheostomy ventilator connection and
minimise air leaks
Assemble IPPB circuit, filling the nebuliser chamber with 5mls Drug is given as prescribed and
of sterile, normal saline. Check the saline amount and expiry avoids administration errors
date with another qualified member of staff e.g. nurse or Provides humidification to the
physiotherapist inhaled gas

Attach circuit to ventilator To establish ventilator patient

connection
Connect IPPB ventilator to 02 gas supply. Maintain the patients To establish driving gas source
current Fi02 where indicated until treatment is ready to and maintain adequate Fi02
commence. The O2 IPPB ventilator will only provide
approximately 40% 02
Switch ventilator on and demonstrate function to patient using Ensures correct functioning of
the red manual override control on the left hand side of the the ventilator.
ventilator Establish absence of leaks in
the circuit
Provides patient reassurance

Configure initial settings:

Sensitivity or starting effort Set low to allow patient to breath in

easily without increasing work of
breathing

Inspiratory Flow Rate Commence at mid range. Increase if

patient is very breathless, then reduce
as able to optimise gas distribution

Commence at approximately 10 cmH20

Inspiratory Pressure Increasing as necessary according to
patient response

Prevents the machine cycling

automatically
All other controls should be switched off
Ensures the correct technique and
maximises the effectiveness of the
Apply interface and commence treatment. Instruct the treatment
patient to initiate a breath and then allow the machine
to fill their lungs with air, then to breathe out passively

Intermittent positive pressure breathing (IPPB) Guideline 2015 3

Use the red manual override control if the patient Ensure correct technique and maximise
needs help initially to coordinate with the ventilator effectiveness of intervention
Monitor the patient throughout the treatment: Ensure patient safety including
For any signs of distress adequate Fi02
Synchrony with ventilator
Thoracic expansion N.B. The BIRD will only supply 40% 02
Cheek filling
Air swallowing
Abdominal distension
Pulse oximetry
Cardio-vascular instability
Adjust the settings as required to match patient Maximise effectiveness of intervention
demand, progress and treatment
Continue treatment for as long as required. Reduce Prevent hyperventilation and hypocarbia
inspiratory pressure intermittently if using over a
prolonged period
Add manual techniques as required Maximise effectiveness of treatment
promotes removal of secretions
If a cough is stimulated, discontinue IPPB temporarily Allows the patient to expectorate
Once the treatment has finished restore pre-treatment Re-establish respiratory support
respiratory support
Monitor the patients observations to ensure level of Maintains patient safety
support is still adequate
Rinse out the nebuliser chamber with sterile water Prevents the potential for bacterial
and dry thoroughly contamination
Use a patient hospital label to identify the patients Prevents cross contamination
IPPB circuit and store in a plastic bag by the patients
bedside
IPPB circuits should be changed on a weekly basis For infection control purposes
the date of commencement of the use of the circuit
should be clearly marked on the hospital label
Report any adverse effects or changes in patients Patient safety
overall condition to nursing and/or medical personnel
Document procedure, effects and response as per Legal requirement
documentation policies

Intermittent positive pressure breathing (IPPB) Guideline 2015 4

Best Practice

Training

IPPB will not be performed by physiotherapy or nursing staff who have not been trained and been
deemed competent

Education will be a mandatory inclusion in the in-service training programme for the Band
5 physiotherapy staff respiratory rotation
Education will be offered in the emergency duty induction programme
Opportunities will be offered to senior staff wishing to maintain their skills in IPPB

Treatment

IPPB should only be applied when clinically indicated and then proven to have been effective.

All of the mechanical effects of IPPB are short lived, lasting less than an hour after treatment. The
therapist must therefore aim to maximise treatment carry over by educating the patient, the
carers and the multi-disciplinary team.

Intermittent positive pressure breathing (IPPB) Guideline 2015 5

Equipment List

1. Oxygen or air gas supply

2. IPPB ventilator (air or oxygen)
3. Ampoule of sterile normal saline (checked and prescribed)
4. IPPB circuit to include:
a. Appropriate patient interface (facemask, mouth piece or catheter mount for
tracheostomy patients)
b. Connector tubing (wide bore tube and narrow bore tube)
c. Complete nebuliser unit
d. Exhalation valve

References

AARC Clinical Practice Guideline IPPB (2003) Respiratory Care 48,5: 540-546

Bott J et al (2009) Guidelines for the physiotherapy management of the adult, medical,
spontaneously breathing patient. Thorax 64: (Suppl 1)ii-i151

Bott J and Keilty S and Noone L (1992) IPPB A dying art? Physiotherapy 78, 9: 656-660

Denehy L and Berney S (2001) The use of positive pressure devices by physiotherapists.Eur
Respir J 17: 821-829

Acknowledgement

The authors would like to acknowledge Fiona Moffatt, Critical Care Outreach Physiotherapist at
QMC for her help in producing these guidelines.

Intermittent positive pressure breathing (IPPB) Guideline 2015 6

IPPB Troubleshooting
Problem
Machine does not function
Machine cycles of its own volition
Patient is unable to trigger the
machine
Machine keeps delivering a breath
and does not stop
Machine seems to deliver a jerky
breath / patient resists the inspiratory
flow
Patient complaining of breathlessness/
difficulty breathing in or not getting
enough air
Patient complaining of the machine
blowing too hard
Patient grimacing/ cheeks filling /
active expiration (abdominals
contracting)
Poor thoracic expansion despite IPPB
Patient still unable to clear secretions
Intermittent positive pressure breathing (IPPB) Guideline 2015
Possible Solution
Check it is switched on
Check the gas supply is inserted correctly into
the wall
The starting effort may be too low and
movement triggers a flow of gas
Check that the controlled expiratory time switch
is off
Starting effort may be too high
Inadequate seal at the interface
If using a mouthpiece a nose clip may be
required
Inspiratory pressure may be set too high
Loss of a seal at the interface may lead to the
pre-set pressure not being reached
Starting effort may be too low, therefore the
patient is unable to synchronise with the sudden
breath
Inspiratory flow rate is too high, therefore the
patient is unable to synchronise with a rapid
breath
Poor patient technique
Starting effort may be too high leading to
increased work of breathing
Inspiratory flow rate may be too low, not
matching the patients requirements
Inspiratory pressure may be too low not
matching the patients requirements
Inspiratory pressure set too high
Patient may be in pain
Poor technique
Unsuitable ventilator settings
Inspiratory pressure may be set too low (may
need increasing if patient has reduced lung
compliance)
Inappropriate/ inadequate patient positioning
Inspiratory flow needs reducing to improve gas
distribution and prolong inspiratory time
? VT sufficient for an effective cough
? Presence of secretions
? Adequate humidification/hydration
? Intact cough reflex
7
 APPENDIX 1

Disposable IPPB Circuit

Exhalation
valve

Wide bore and

narrow bore
tubing Mouthpiece

Nebuliser

IPPB Ventilator

On/Off
switch

Starting
effort dial Inspiratory
pressure
dial

Red Port for

manual connecting
over-ride IPPB circuit
control
(not
seen)

Inspiratory Controlled Inspiratory

pressure gauge expiratory time flow rate
(switch to off) dial

Intermittent positive pressure breathing (IPPB) Guideline 2015 8