December, 1968 P H Y S I O T H E R A P Y Page 11 The modified Rehabilitation Stairs, n o w available, contain the following features: Total length: 105 inches. T otal w idth: 36 inches. ^ Steps and Central Platform are covered with rubber matting in., having a diam ond mesh pattern. Steps: All steps have a length o f 15 inches. There are 3 steps on one side o f 8 in. depth and 4 steps on the op p osite side of 6 inches depth. Central P latform : H as a depth o f 39 inches at a height o f 24 inches from the floor. Rails: Provided on both sides, detachable, held in place by wing nuts. B ein g detachable enables easier transport, thus reduces the total cost and allow s a therapist to rem ove one rail if desired. A n additional feature which m ay be ordered by those centres with a high num ber o f patients, as Paraplegics, w h o com m ence stair training using tw o rails is a second placem ent position for one rail, at the width o f 32 inches as well as the standard w idth o f 36 inches. T he rail at the placem ent o f 32 inches w ould how ever have slight “play” com pared to the p osition at 36 in. Construction: P hillopin o M ahogany is used for the sides, rails and upright pieces o f the steps. T he top shelf, platform and the steps are constructed o f $ inches co n te sh e lf which is stronger than the norm al w o o d and the step support and frame is o f i inch Sou th A frican Pine. A recent m odification, not sh ow n on the photograph, is the raising o f the height o f the rails ab ove the platform to the sam e height ab ove each step and the exten sion o f the slop e o f the rails upwards at the edges o f the platform . It is also planned to investigate the p ossibility a o n e rail being m etal, adjustable in height and capable o f sw inging in­ wards, thus enabling the w idth betw een the tw o rails to be reduced easily. It is therefore advocated for reasons o f increased safety and greater variety in training that these stairs b e c o n ­ sidered in preference to the form er type. A n y suggestions for further im provem ents in design w ill be w elcom ed. T he stairs are available from : Protea E lectro-M edical C om pany at an approxim ate price o f R 170. A ckn ow led gem ent: Protea E lectro-M edical C om p any in revising their design and dealing w ith a fem ale non-crafts­ man-carpenter ! Notes on Uses of the Bird Respirator Treatment by Physiotherapy B y J. M A L C O L M , M .N .Z .S .P . Patients w h o benefit from treatment with the Bird R es­ pirator fall into three main groups. 1. The C o-operative patient. 2. T he U n co-op erative patient. 3. T he U n con sciou s patient. Group I. This group falls into tw o section s again. (a) Chronic Lung D iseases: B ronchitis, Em physem a, A sthm a. (b) P o st O perative P atien t, and acute respiratory diseases, (a) Chronic Lung D iseases. Aims o f Treatment. (i) Increase the flow o f air through congested bron­ chioles. (ii) F ully expand stiff and rigid chest and increase the m ovem ent o f a fixed or partially fixed diaphragm. (iii) Introduce nebulized broncho-dilators into the bronchioles for relief o f oedem a and spasm . (iv) Clear m ucus and secretions from the chest. M ethods o f Treatment. (i) P osition the patient where possible. U se postural drainage position s to aid the m ovem ent o f m ucus to the m ain bronchus where it can be easily coughed out. (ii) U se the m ou th piece o f the Bird fitted to the neb u ­ lizer (into which the broncho-dilator prescribed, or distilled water, has been added). (iii) Set dials o f m achine as follow s: Flowrate: U se a long flow rate depending on the patient’s capacity (i.e. size o f chest, am ount o f effective lung tissue left, age o f patient). A long flow rate is between 7-15. This introduces positive pressure slow ly so that air pushes gently past secretions to expand collapsed alveoli and enables patient to cou gh ou t m oistened secretions lying in the airway. Even if the patient is to o depressed to cough, gases flowing out o f the lung gradually propel secretions out o f the peripheral airways. Respiratory Pressure: Set again according to patient’s capacity: 15 is considered norm al for an adult, but a man with healthy lungs will take up to 25 com fortably. Air M ix : T his sh ould be pulled full out to give 40° 0 2 and 60° atm ospheric air. Respiration Effort. Set at 40, unless patient very w eak. T his indicates the am oun t o f effort the patient m akes to trigger the respirator, and sh ould be m ade fairly difficult for the voluntary patient. (iv) Instruct patient in use: H o ld the m outh piece in his m outh , gently pinch his nostrils together so air does n o t escape through nose. Teach him to relax on inspiration and let all the air flow into lungs and n o t cheeks. Tell him n o t to block the flow o f air by closin g his throat or blocking the m outh piece with his tongue. (v) E xpiration: Encourage to breathe out as far as possible. H elp by pushing o n low er ribs and pushing diaphragm up. (If patient is tipped the weight o f the viscera will also help diaphragm to m ove upwards). Footnote: W ith asthm atics, low er the inspiratory pressure; use prescribed bronchod ilator and encourage long, relaxed expiration. I f at first y ou w ish to retard the expiratory phase to teach patient to expire slow ly and in a relaxed fashion, use the “ retard guard” which yo u w ill find attached to machine. (b) P o s t O perative P a tie n t and A cu te R espiratory D iseases. In this group is included— 1. P ost operative laparotom y where there is chronic chest disease. 2. T h orocotom y and lobectom y. 3. Pneum othorax. 4. H aem oth orax. 5. Spinal Injuries. 6 . Injuries o f Chest. 7. A telectasis. 8. A cu te infection o f chronic chest conditions. Aim s o f Treatment. (i) M aintain adequate exp an sion o f lungs and good interchange o f air. (ii) Increase flow o f air into collapsed bronchioles. This is effected by the positive pressure on inspiration. (iii) A ssist expectoration. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page 12 P H Y S I O T H E R A P Y December, 1968 (iv) D ecrease the am ount o f pain and effort necessary to keep lung expanded. (v) Re-establish a g ood cough reflex and good voluntary breathing habits where possible. M ethods o f Treatment. (i) I f possible treat the patient pre-operatively. Teach him how to use the Bird with the m outh piece. Show him the position s you will use and teach him to cough “w ith” the respirator (i.e. use the respirator for in sp iration ; rem ove the m outh piece, and cough). (ii) M easure the tidal volum e pre-operatively with a spirometer. T his will give you som e indication for setting the inspiratory pressure o f the machine afterwards. (iii) Position the p a tie n t: W hen treating pneum othorax, haem othorax; thorocotom y and acute infections, lie patient dow n on the opp osite side with a pillow under his chest. This helps to limit the intake o f air to the g ood side: elim inates the spinal scoliosis which has nearly always d evelop ed ; and aids expiration (the weight o f the viscera pushes up on the diaphragm). Back cases cannot be turned but in all cases tip the bed. (iv) Set the m achine 1. Slow inspiratory time flow. 2. Effort: high. 3. Pressure according to patient and condition. (v) If it does not cause to o m uch pain in the first stage, assist expiration. Encourage patient to force expiration. M ucus and secretions should m ove towards the pharynx easily. (vi) U se the nebulizer to soften and loosen secretions. (vii) The patient sh ould take over from the Bird as soon as the acute stage is over. Even if the collapsed lung is well expanded with the Bird, the patient m ay no t be able to expand it well voluntarily. Teach this with the usual post-operative routine. Group 2. The Unco-operative Patient. This is the patient in acute respiratory failure or acidosis. H e still has a cough reflex and a patent airway. D u e to carbon-dioxide narcosis he may be dazed, belligerent or psychotic, cyanosed, gasping for breath or unwilling to co-operate. Aims o f Treatment. (i) R estore adequate tidal air flow as quickly as possible. (ii) D rainage o f secretions. (iii) R estore breathing to a point where patient can provide enough alveolar gas exchange unassisted and spontaneously. Method. (i) Try to stop patient’s panic. R em ain calm yourself. (ii) Lie the patient supine with shoulders raised 20° and head tilted backwards (this keeps the larynx open). Pull the patient’s jaw forward. (iii) A n airway m ay be necessary. (iv) Select a well fitting mask to cover nose and m outh. H old this firmly so that no air escapes. (v) M ake sure the nebulizer is full. (vi) Set the m achine 1. Easy effort. 2. Small pressure. 3. Short flow rate. A s the patient’s con d ition improves, lower the shoulders and tip the end o f the bed so secretions can drain more easily. T hen gradually increase the pressure and flowrate and the inspiratory effort. (vii) A id expiration. (viii) W hen the patient coughs, encourage him and sit him up. (ix) The patient should stay on the respirator until his condition im proves sufficiently to take over himself. (x) The m achine sh ould be used intermittently, as for the co-operative patient, when he has recovered. (xi) Teach breathing exercises as for the co-operative patient. Tracheostomy Patient. This is again divided into tw o groups. (1) Flaccid, unconscious p a tie n t w ho is not breathing voluntarily, (i.e. Tetanus, when patient has been given large doses o f m uscle relaxant; over d ose o f drugs, p o lio - high spinal chord lesions affecting m uscles o f respiration)! The patient usually has little or n o cough reflex. Treatment. The patient will be on continuous artificial respiration and taken o ff only for suctioning and artificial coughing with ambru bag. W hen first applying m achine to patient, set all controls at 15 (This now includes the autom atic respiratory control knob as the patient is not triggering the m achine) N .B . do not use the negative pressure switch. When the m achine is going and everything is set up, charge the settings as required and take a tidal volum e reading with a spirometer. Check several things h alf hourly. 1. Spirometer readings should remain the same, if they do n o t it indicates (a) block in tubing, (b) leak in circuit. 2. Check the cuff. It should allow a very sm all am ount o f air to leak past to propel secretions around it upwards (on inspiration) where they can be sucked from the pharynx. 3. H a lf hourly or hourly let the c u ff'd o w n quickly: su ction: and blow cuff up again. Thisjrests the mucus m embrane around the cuff and allow s secretions to m ove dow n into the trachea where they can be sucked out. The respirator will have to be disconnected while suctioning. 4. Check the nebulizer: it must never run dry. 5. Check the tubes o f the respirator for water accum u­ lation; shake them dry when necessary. 6 . A lw ays watch for respirator jum ping— this indicates obstruction. 7. W hen suctioning introduce 15 cc o f sterile saline into the tracheostom y to soften m ucus and prevent crusting. 8 . I f an 0 2 cylinder is being used, check for pressure. This should always remain higher than 64 lbs. ( = to 500 cc O a content) o f pressure. The Artificial Cough. Tw ice daily, or m ore if necessary, transfer patient to the ambru bag. Tip the bed for a full tip. T w o operators are necessary. One to squeeze the bag fully and slow ly w hile the other presses sharply o n the chest during the expiratory phase to effect a cough or sharp expiration. Suction during this when necessary. (2) The C o-operative T racheostom y P atient. Treatment. (i) W hile the patient is continually on the respirator encourage him to assist expiration and relax with the m achine on inspiration. (ii) Try to encourage the cough reflex w hile tipping and suctioning. If patient is very debilitated or the cough reflex is dim inished it may be necessary to use the ambru bag and artificial cough. (iii) Try to w ean patient o ff m achine as so o n as his con d ition improves. Let the cuff dow n while patient is off m achine and encourage breathing and coughing through the m outh as well as the tracheostom y. Then teach him to breathe through his m outh only by blocking o ff the tracheostom y with his finger. Start taking patient o ff m achine for 5 m inutes and if he sh ow s n o sign o f distress gradually increase the time. (iv) W hen patient is coughing well voluntarily and breathing through both tracheostom y and m outh the tube m ay be rem oved. Air will escape for a few days through incision. Teach breathing exercises and cough with pressure over incision site to prevent this. (v) Throughout treatment continue to teach localized breathing exercises and postural drainage if necessary. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )