The positive Inspiratory to Expiratory I/E ratio is programmed in seconds. The pressure differential behind the tidal volume delivery is inter-dependent upon the gross intrapulmonary resistances. Thus an accelerating flow/pressure gradient is held against the entire pulmonary airway until the required positive delivery pressure is reached and/or upon failure to deliver the Tidal Volume. The PIP is then held against the pulmonary airways (apneustic plateau) until the selected Inspiratory time is mechanically terminated.
UNDERSTANDING THE BASIC CONVENANTS OF INTRAPULMONARY PERCUSSIVE VENTILATION (IPV®-VDR®) AS A LUNG RECRUITMENT AND MAINTENANCE VENTILATION PROTOCOL WITH A CONCEPTUAL LUNG PROTECTIVE STRATEGY.
The Percussive Ventilation of the lungs provide for a powerful means of Lung mobilizing through Bronchiolar “Lung Recruitment” and the stabilizing of the recruited peripheral pulmonary airways which is directed toward increasing alveolar ventilation.
Concomitant with Percussive Pulmonary gas exchange, a dense therapeutic aerosol is topically delivered throughout the endobronchial structures.
The percussive higher rate (frequency) delivery of sub tidal volumes of respiratory gases into the pulmonary structures serves to provide for a “Newtonian” pumping action within the elastomeric endobronchial airways to mobilize and raise endobronchial secretions. Unique IPV® programming can accommodate all patient populations from neonates through pediatrics to large adults.
As the patient breathes through a mouthpiece, mask or endotracheal tube, the IPV® Percussionator delivers mini-bursts of respiratory gases into the lungs at selected rates of from 100 to 300 cycles per minute. Generally, the patient only takes a breath when physiologically mandated and/or desired, allowing the Percussionator® to do the patient’s “work of breathing”.
During the percussive bursts of gas delivered into the pulmonary airways, a continuous endobronchial pressure wedge is maintained.
While pulsatile intra-airway oscillatory pressure changes occur, between baseline and the oscillatory plateau, the recruited Bronchial airways are maintained in a semi-dilated state as cyclic pressure changes occur.
During therapeutic percussion an aerosol mist is delivered throughout the lungs by the high output aerosol generator of the Intrapulmonary Percussionator® breathing head assembly.
Aerosol misting within the endobronchial airways reduces the adhesive and cohesive forces of the retained secretions, decreases swelling within their walls, and relaxes potential spasm of the terminal bronchioles (small airways) of the lungs. The pulsatile intrapulmonary exchange of well-mixed respiratory gases serves to convectively flush out carbon dioxide and diffusively renew alveolar oxygen.
Uniquely, millisecond IPV® Sub Tidal intrapulmonary injections do not hold a sustaining CMV Tidal Exchange positive pressure against the pulmonary airways in seconds. This is a conceptual means of maintaining a LUNG PROTECTIVE STRATEGY with IPV®-VDR® scheduling, to prevent hyperinflational Barotrauma.
Notes:
Pulmonary Airways by Netter courtesy of Ciba®
The lower presentation of a general cross-section of the Bronchioles (terminal pulmonary airways) reveal the potential millions of small peripheral Bronchiolar airway serving their Alveoli.
Patient’s with Bronchitis associated with the various types of peripheral lung diseases have a diffuse mix of Bronchiolar airway lumens (caliber).
Certain Bronchioles have little or no airway narrowing, while others have airways with minor to severe obstructions caused by endobronchial edema and retained airway secretions as well as other factions.
If a mechanically induced timed positive distending pressure during volume-pressure CMV Lung Ventilation, is held against the cross section of diseased Bronchial airways with various patencies (degrees of obstructions) with interspursed “non-obstructed Bronchiolar airways”, which airways will be the first to be mechanically inflated to the peak positive distending pressure?
The intermingled non-obstructed Bronchial airways will allow a PREFERENTIAL inflow into their Alveoli in the presence of other more obstructive Bronchioles during a mechanical Tidal Volume delivery. These unobstructed Bronchiolar airways are called PREFERENTIAL Bronchiolar airways. When scheduled intrapulmonary Tidal Volumes are delivered under moderate or high peak pressure limits secondary to gross endobronchial resistances, the open (non-obstructed) Bronchiolar airways are initially PREFERENTIALY hyper-inflated. The hyperinflation creates Alveolar barotraumas leading to pneumothoricies. Thus the dependent (life supporting) Alveoli are the first to be damaged by hyperinflation encroaching upon the patient’s disease limited life support pulmonary reserves. Thus, the volume-pressure CMV ventilation of patient’s with peripheral obstructive lung diseases can create critically injures.
Thus volume-pressure ventilation of the lung with bronchiolar disease can be a major cause of hyperinflational barotraumas.
Notes:
THE ABOVE SCHEMATIC DEMONSTRATES THE VARIOUS DEGREES OF PERIPHERAL PULMONARY AIRWAY OBSTRUCTIONS, AS WELL AS THE “NON-OBSTRUCTED PREFERENTIAL AIRWAY”. NOTE: THE POTENTIAL FOR MECHANICALLY AGRAVATED “ALVEOLAR AIRWAY GAS TRAPPING”.
Notes:
The above drawing reveals the lumen (patency) of a non-obstructed PREFERENTIAL Bronchial airway and the Bronchiolar airway narrowing by obstructive edema and retained airway secretions. Additionally, the Goblet cells secreting thick tenacious mucous secretions retard ciliary function and mucus retention, which if retained, provide for advancing Bacterial culturing.
ROUTES OF AND AGENTS TYPICALLY USED FOR COPD PHARMACEUTICAL DRUG ADMINISTRATIONS-
- They can be delivered orally for systemic absorption, in pill form and/or injected or infused intravenously, into the systemic blood circulation.
- They can be delivered into the Pulmonary Airways of the Lungs as a topical aerosol (mist) for absorption by the circulatory blood vessels within the walls of the pulmonary airways; as well as, transported by the Lymphatic circulation from the Lungs centrally into the systemic venous blood circulation.
a). The topical effectiveness of the aerosolized drugs is related to the “site delivery” of topical aerosol particles, which is in part dependent upon the depth of aerosol particulate delivery, within the Pulmonary airways. Typical Nebulizer (aerosol generators) “rain out” the aerosol particles before they reach the peripheral Bronchiolar airways. Therefore, the main effect from the aerosolized drugs is created by the systemic absorption of the aerosolized pharmaceuticals into the systemic circulation, and not the desired endobronchiolar topical delivery effect.
The nature and action of typical COPD medications.
- Anti-histiminics- Primary side effect (predominately in males) is difficult urination.
- Steroids including their synthetics- defined as anti-inflammatory agents, serves to mask Bronchiolar inflammatory processes.
- Beta Bronchodilators- Serve to relax Bronchiolar smooth muscle contractions, associated with asthma.
- Alpha-Beta Agents such as legend Racemic Epinephrine-
- As an Alpha, serves as a vasoconstrictor (with comparable minimal rebound effect) to reduce bronchiolar mucosal and sub mucosal edema.
- As a combined Beta serves to act as a Bronchodilator to relax Bronchiolar smooth muscle spasm in Asthmatic patients.
- Using Water as a diluent creates a favorable Osmotic Endobronchial Pressure, causing a more rapid endobronchial absorption into the Bronchiolar Basement Membranes to reduce Bronchiolar airway edema.
Note: Many years of experience with legendary aerosolized aqueous Alpha Beta Racemic Epinephrine solutions, delivered during Intrapulmonary Percussive Ventilation (IPV®) have demonstrated a lengthening of the time the pulmonary Bronchioles remain recruited after routine IPV® therapy.
The following copyrighted © data was researched, prepared and edited in 2009 by the
