|
Selecting an Approach |   |
| The best way to achieve a given clinical goal is always the safest, simplest and most effective method for the individual patient. In order to make the right selection the RCP needs to have in-depth knowledge of both the methods available and the specific condition, and needs of the patient being considered for therapy. |
|
The patient must first meet the criteria for therapy by having one or more of the indications previously specified. For patients meeting the inclusion criteria, the RCP first determines the degree of alertness. Since an obtunded patient cannot be expected to cooperate with IS or PEP/EPAP therapy, IPPB at 10 to 15 mL/kg is initiated with appropriate monitoring. If the patient is alert, a bedside assessment is conducted, including measurement of either the inspiratory or vital capacity, and evaluation of the volume and consistency of the patient's secretions.
For patients having no difficulty with secretions, if the VC exceeds 15 mL/kg of lean body weight, or the IC is greater than 33% of predicted, incentive spirometry is appropriate. If either the VC or IC is less than these threshold levels, IPPB should be initiated, with the pressure being gradually manipulated from the initial setting to deliver at least 15 mL/kg.
If excessive sputum production is a compounding factor, a trial of PEP therapy can be substituted for IS, and based on patient response, bronchodilator therapy and bronchial hygiene measures may be added to this regimen.
If monitoring fails to show improvement and atelectasis persists, a trial of CPAP should be considered. Since evidence regarding the effectiveness of CPAP is still contradictory, its current use should be limited to treating atelectasis after alternative approaches have been tried without success.