noninvasive pressure support ventilation
Contents
1. MN NONINVASIVE PRESSURE SUPPORT VENTILATION by Kevin T Martin BVE RRT RCP V7116HC 03 C 1 110000 071166 RC Educational Consulting Services Jne P O Box 1930 Brockton MA 02303 1930 800 441 LUNG 877 367 NURS www RCECS com Noninvasive PRESSURE SUPPORT VENTILATION BEHAVIORAL OBJECTIVES UPON COMPLETION OF THE READING MATERIAL THE PRACTITIONER WILL BE ABLE TO 1 discuss operational principles of noninvasive pressure support ventilation NIPSV 2 name the advantages of NIPSV 3 describe indications for NIPSV 4 compare and contrast indications and contraindications for NIPSV 5 describe the complications of NIPSV 6 explain how to determine the proper patient interface to deliver NIPSV 7 provide initial patient set up parameters for NIPSV 8 describe techniques preformed to manage and monitor patients receiving NIPSV 9 demonstrate critical thinking skills during a clinical practice exercise using the information gained in the reading material COPYRIGHT 1995 By RC Educational Consulting Services Inc COPYRIGHT April 2000 By RC Educational Consulting Services Inc TX 4 020 348 Authored 1995 by Kevin T Martin BVE RRT RCP Revised 2001 by Michael R Carr BA RRT RCP Revised 2003 by Susan Jett Lawson RCP RRT NPS Revised 2006 by Helen Schaar Corning RRT RCP Revised 2010 by Aimee D Staggenborg MA BA RRT Edited 2010 by RCECS Staff ALL RIGHTS RESERVED This course2. so gastric distention may not be a problem However the patient must be monitored for this complication Tissue breakdown is possible if the mask size is improper or the seal is too tight The most common site of tissue damage is on the bridge of the nose for nasal masks In addition to utilizing the correct size mask and ensuring the seal is not too tight tissue breakdown may be prevented and or resolved with protective wound dressings on the bridge of the nose or by trying a different type of mask nasal prongs or nasal pillows COMPLICATIONS WITH NIPSV e leaks around mask e skin reddening and breakdown e eye irritation from air leaks e dry nose and or upper airway e facial discomfort e gastric distension If the patient does not feel comfortable with the therapy because of claustrophobia and skin irritation try changing the interface to one that is more easily tolerated by the patient The use of topical lotions and nasal sprays that contain steroids and antihistamines can be used to treat nasal dryness associated with the use of NIPSV Humidifiers in line can also alleviate this problem Masks should be cleaned daily to remove dirt and facial oils The occasional mouth breathing patient whether it s partially or all the time presents the problem of pressure leaks Chinstraps don t seem to resolve the problem Changing the interface to an oral nasal mask may be required to prevent the leaks 14 Chis material is copyrighted
3. C Martin T King T Schraufnagel D Murray J F amp Nadel J A 2010 Murray and Nadel s Textbook of Respiratory Medicine 5th edition WB Saunders Company Phillips Respironics Inc 2009 Bi PAP AVAPS Average Volume Assured Pressure Support Non Invasive Ventilatory Support Product Information available at http bipapavaps respironics com Phillips Respironics Inc 2009 Bi PAP autoSV servo ventilation Non Invasive Ventilatory Support Product Information available at http bipapautosv respironics com Respironics INC BiPAP S T User Manual http global respironics com UserGuides BiPAP ST User Manual pdf Talk About Sleep Inc n d Sleep Disorders Available online at http www talkaboutsleep com sleep disorders index htm Whitaker Kent B 2001 Comprehensive Perinatal and Pediatric Respiratory Care 3 edition Delmar Learning 24 Chis material is copyrighted by RC Educational Consulting Services Inc Unauthorized duplication is prohibited by law Noninvasive PRESSURE SUPPORT VENTILATION Wilkins R L Stoller J K amp Kacmarek R M 2009 Egan s Fundamentals of Respiratory Care 9 Edition Elsevier Science Wyka K A Mathews P amp Clark W F 2001 Foundations of Respiratory Care Delmar Learning Chis material is copyrighted by RC Educational Consulting Services Jne Unauthorized duplication is prohibited by law 25 Noninvasive PRESSURE SUPPORT VENTILATION POST TEST DIREC
4. allows the patient to speak and expectorate without removal of the mask Nasal masks are more comfortable and easier to keep in position than facemasks There is also less danger of aspiration with a nasal mask A facemask gives more consistent control of pressures if the patient breathes through the mouth There are other advantages and disadvantages to each type of mask Select the most appropriate for the patient Carefully fit the mask selected Mask type and size are critical to successful application and patient overall compliance with NIPSV Both nasal and full face masks should rest one third to one half the way down the bridge of the nose and snugly along the lateral border of the nose If Chis material is copyrighted by RC Educational Consulting Services Jne Unauthorized duplication is prohibited by law 15 Noninvasive PRESSURE SUPPORT VENTILATION they rest high on the bridge of the nose leaks about the eyes are common Facemasks should cover the mouth and nose completely they should be neither too large nor too small and should not interfere with the eyes or go below the chin For nasal masks choose the smallest that completely covers the nose Masks that are too small will cause excessive pressure on the bridge of the nose As mentioned above it is wise to place a patch of wound care dressing on the bridge to minimize pressure trauma Nasal masks should fit around the end of the nasal bone to just below the nares and above the u
5. be more effective in these patients TABLE 2 CONTRAINDICATIONS TO NIPSV e life support ventilation e severe cardiac arrhythmias e significant hypotension e bullous pulmonary disease e pneumothorax e facial trauma skull fractures e severe dementia e high ventilating pressures e high or precise FIO necessary e rapidly changing pulmonary compliance e hyperventilating patients e no cough reflex swallowing dysfunction e excessive secretions upper GI bleeding e nasal obstructions relative contraindications see text for further explanation Chis material is copyrighted by RC Educational Consulting Services Jne Unauthorized duplication is prohibited by law 13 Noninvasive PRESSURE SUPPORT VENTILATION COMPLICATIONS NIPSV are those associated with positive pressure ventilation and mask CPAP Some complications include decreased venous return decreased cardiac output pneumothorax Aspiration is possible if a facemask is used A nasal mask minimizes the possibility of aspiration All NIPSV patients should also have intact upper airway reflexes to protect the airway Tew complications have been reported with NIPSV However reported complications of There may be gastric distention with swallowed air Insertion of a nasogastric tube may be necessary especially if the patient is using a full face mask Generally NIPSV pressures are not high enough to overcome esophageal sphincter pressures approximately 20 to 25 cmH20
6. by RC Educational Consulting Services Jne Unauthorized duplication is prohibited by law Noninvasive PRESSURE SUPPORT VENTILATION EXCLUSION CRITERIA FOR SUCCESSFUL NIPSV e respiratory arrest e pneumothorax e uncontrolled arrhythmias e airway obstruction e unable to clear secretions e uncooperative e facial trauma e systolic blood pressure lt 90 mmHg PATIENT SET UP success considerably The importance of communication and reassurance in the initial stage of NIPSV administration cannot be overemphasized Some patients are immediately comfortable with the mask and NIPSV while many take some time to get used to it Do not overlook this period of conditioning A s with most procedures patient cooperation and understanding enhance compliance and The first step in patient set up is to obtain baseline monitoring parameters according to institutional or care setting policy Suggested monitoring parameters are breathing frequency or respiratory rate RR heart rate blood pressure ABGs or oximetry end tidal CO PETCO breath sounds and use of the accessory muscles of respiration Use of the accessory muscles is an indicator of increased work of breathing NIPSV should reduce work and therefore decrease accessory muscle use Noninvasive positive pressure ventilation can be applied with a nasal mask full face mask nasal pillows nasal prongs or mouthpiece with lip seal The nasal mask may make the patient feel less claustrophobic and
7. is for reference and education only Every effort is made to ensure that the clinical principles procedures and practices are based on current knowledge and state of the art information from acknowledged authorities texts and journals This information is not intended as a substitution for a diagnosis or treatment given in consultation with a qualified health care professional Chis material is copyrighted by RC Educational Consulting Services Jne Unauthorized duplication is prohibited by law Noninvasive PRESSURE SUPPORT VENTILATION TABLE OF CONTENTS INTRODUCTION aussage 4 Ventilators Used For Noninvasive Positive Pressure Ventilation NIPSV 4 ADVANTAGES AND DISADVANTAGES OF NIDSN 7 INDICA TT NS ii 7 Short Term Venta sa RE 8 o A a IS AA 10 att A es 11 Benchicial Effects EE 11 Intermittent USE a eere ee eier 12 CONTRAINDICATION E 12 COMPLICATION S an an ss A E EO REAR 14 Exclusion Criteria For Successful NIPSV u wa 15 ASTIN TSE PSUR ar ee ee ee een 15 INITIAL VENTILATOR SETTINGS u 002 0 000800 denia rod dans rar dv 16 MANAGEMENT AND MONTTORING 19 Improve OV DE EE 20 Improve V ent lat on 20 Optimize Patient Ventilator Synchrony ooooooccninonoccconooacnnonononcnnnonnnnononcnnnnnnononnnnnnnno 21 Weaning Criteria E 21 Noninvasive Positive Pressure Ventilator Adrustmentzs 21 CLINICAL PRACTICE EXERCISE na ao bes el da 22 2 Chis material is copyrighted by RC Educational Consulting Services Jn
8. supplied There is no cycling between the EPAP and IPAP pressure levels The patient still receives PSV breaths in the spontaneous mode on BiPAP On conventional ventilators spontaneous modes imply no ventilator assisted breaths Spontaneous usually means a flow of gas is available to the patient but not pressure support On the BiPAP spontaneous mode means there s no timer active to deliver a breath without spontaneous patient effort The patient can still receive a pressure supported breath when the machine cycles to the IPAP pressure set on inspiration Spontaneous timed and timed modes allow for cycling of IPAP a PSV breath to be provided through a timer Spontaneous timed is similar to SIMV with pressure support and CPAP If the patient does not trigger the ventilator within a given time period a breath is provided A back up respiratory rate must be selected for the spontaneous timed mode Set the ventilator breaths per minute BPM control slightly below the patient s spontaneous RR to ensure an adequate minute volume The timed mode is similar to controlled ventilation The ventilator regulates both inspiratory and expiratory times BPM and percent of inspiratory time must be selected for the timed mode Ventilator BPM is set slightly above the patient s spontaneous RR The BPM selected determines the total time for inspiration and expiration The percent of inspiratory time control determines how long inspiration will be of the tota
9. the ventilator being used Throughout this course the term BiPAP is referenced to the Respironics ventilator There is also the VPAP ST A ResMed Inc and the GoodKnight 425ST Bi Level Device Puritan Bennett Covidien The operating manual for the system being used should be consulted to see if inspiratory pressure support is actually provided Bilevel positive pressure does not always mean pressure support is provided on inspiration Bilevel simply means there are 2 levels of positive pressure one level usually higher on inspiration and a different level usually lower on expiration Both levels can be independently adjusted The inspiratory positive airway pressure IPAP provided regulated is determined whether pressure support is being provided to the patient or not The mechanism employed by the BiPAP S T D and Vision ventilators to maintain pressure is unique It consists of a pressure control valve that alternately restricts or enhances flow to the patient by allowing more or less leaking through the valve If pressure in the circuit begins to rise above that set by the practitioner the valve increases the amount of leak Pressure is rapidly returned to the set value If pressure begins to drop below the set value the opposite occurs The amount of leak is diminished by valve closure allowing both flow and pressure to rise in the eircuit Chis material is copyrighted by RC Educational Consulting Services Jne Unauthorized dupl
10. A decrease in RR suggests a decrease in the patient s work of breathing An increase in oximetry suggests improved oxygenation Titrate IPAP PSV to the level providing the lowest acceptable spontaneous RR Titrate FIO and or EPAP to obtain oximetry gt 90 Caution must be taken in this patient to avoid over distention and possible abolition of hypoxic drive CONCLUSION popular during recent years NIPSV can be used for short term long term or nocturnal ventilation NIPSV indications include CHF COPD post operative or sedation recovery mild to moderate hypoxemia post extubation ARF and to avoid intubation for ethical or cost reasons New ventilator and mask designs have made NIPSV more practical and much more Contraindications to NIPSV include life support ventilation necessary severe cardiac arrhythmias or hypotension bullous pulmonary disease severe dementia facial trauma fractures and hyperventilating patients There are few complications to NIPSV and those that do occur are rare Possibilities include aspiration gastric distention and tissue damage from too tight of a mask Nasal masks are preferred over facemasks The initial EPAP setting is generally 3 5 cm H20 The initial CPAP setting is generally 5 cm H 0 The initial IPAP setting is generally 8 cm H2O The initial O flow rate is 2 5 lpm Titrate all the above to achieve the desired clinical response Titrate EPAP CPAP and FIO to achieve adequate oxygenation Titrat
11. EPAP CPAP should be decreased as the patient improves to prevent over distention Chis material is copyrighted by RC Educational Consulting Services Jne Unauthorized duplication is prohibited by law 19 Noninvasive PRESSURE SUPPORT VENTILATION TO IMPROVE OXYGENATION e increase FIO or liter flow e increase EPAP or CPAP increase IPAP or PSV e decrease EPAP or CPAP if over distention suspected There are several options to improve ventilation Again the first is to ensure there are minimal leaks in the system Following that one can increase IPAP PSV levels increase ventilator breaths per minute or increase inspiratory percent time Conversely lowering EPAP CPAP levels improve ventilation if excessive pressures are being used Excessive expiratory pressure increases air trapping and impedes ventilation The obvious solution is a decrease in EPAP CPAP to improve ventilation TO IMPROVE VENTILATION e increase IPAP or PSV e increase BPM e increase inspiratory time e decrease EPAP or CPAP if air trapping suspected Institutional care setting policy guides the practitioner in how much to increase or decrease settings Generally FIO is changed 5 10 or 1 2 Ipm EPAP CPAP and IPAP PSV settings are changed in 2 0 cm H O increments Because the system is noninvasive and subject to variable leaks settings may have to be adjusted often A change in patient position level of activity inspiratory effort or respiratory pattern may requi
12. TIONS Use the FasTrax answer sheet enclosed with your order to respond to all the test questions that follow Leave the remaining answer circles on the FasTrax answer sheet blank Be sure to fill in circles completely using blue or black ink The FasTrax grading system will not read pencil If you make an error you may use correction fluid such as White Out to correct it FasTrax answer sheets are preprinted with your name and address and the course title If you are completing more than one course be sure to record your answers on the correct corresponding answer sheet RETURN TO RCECS P O Box 1930 Brockton MA 02303 1930 or FAX TO 508 894 0172 1 To evaluate the effectiveness of NIPSV the patient MUST be assessed for use of accessory muscles PaCO oximetry respiratory rate allofthe above aaRS 2 The initial EPAP setting in general is usually 8 0 cm H20 7 0 cm H20 3 5 0 cm HO 10 0 cm H20 none of the above Da cs 3 NIPSV is useful for ventilatory life support in most patients a True b False 4 Nocturnal NIPSV for the COPD patient may result in improved daytime PaO decreased daytime PaCO worsening daytime symptoms a amp b none of the above 92078 26 Chis material is copyrighted by RC Educational Consulting Services Jne Unauthorized duplication is prohibited by law Noninvasive PRESSURE SUPPORT VENTILATION 5 Clinical contraindications to NIPSV include 1 severe dementi
13. a 2 acute facial trauma 3 patient with mild hypoventilation 4 acute exacerbation of COPD 2 3 3 4 1 2 1 2 3 4 1 4 vo Ff 6 The initial IPAP setting when EPAP is set at 3 0 cm H20 on the BiPAP ventilator is usually 11 0 cm H20 8 0 cm H20 3 0 cm H20 5 0 cm H20 none of the above mo OG P 7 A potential complication of NIPSV via facemask is aspiration secretion mobilization decreased PaCO improved PaO c amp d oao 8 Which of the following are medical indications for NIPSV post extubation acute respiratory failures down s syndrome acute exacerbation of COPD congestive heart failure BR WN mr 2 3 4 1 3 4 1 2 3 4 3 only Go P Chis material is copyrighted by RC Educational Consulting Services Jne Unauthorized duplication is prohibited by law 27 Noninvasive PRESSURE SUPPORT VENTILATION 9 To improve ventilation for a patient receiving NIPSV the practitioner should oe aS P Increase IPAP PSV increase BPM frequency Increase inspiratory time increase FIO BON ka 1 2 3 4 4 only 1 2 3 3 4 2 3 4 10 To improve oxygenation for a patient receiving NIPSV the practitioner should 11 12 13 28 KEE increase IPAP PSV Increase EPAP decrease IPAP PSV Increase FIO a b amp d The initial setting used to manage acute respiratory insufficiency in a patient breathing spontaneously 12 times per minute is o
14. aterial is copyrighted by RC Educational Consulting Services Jne Unauthorized duplication is prohibited by law Noninvasive PRESSURE SUPPORT VENTILATION Fixed rise time Rise time control Measures proximal pressure Measures amp regulated proximal pressure ADVANTAGES AND DISADVANTAGES OF NIPSV required Consequently there are no complications from the presence of an artificial airway Patients are more comfortable without an airway in place and less sedation is needed The patient retains normal swallowing and airway defense mechanisms The cough effectiveness is not impaired and the glottis can seal the airway to prevent aspiration Patient communication is greatly enhanced because speech is preserved Lastly NIPSV allows intermittent application of ventilatory support r The most obvious advantage to NIPSV is that there is no endotracheal or tracheostomy tube There are disadvantages related to the lack of an artificial airway The practitioner does not have ready access to the airway for suctioning monitoring or emergency ventilation purposes Control over the patients oxygenation and ventilation status is not as assured as with intubation and mechanical ventilation NIPSV uses technology that is simpler than what has been used in the past This meets with some resistance in the clinical setting where one is used to ever increasing technology and control of the patient Additional disadvantages are feelings of cl
15. austrophobia and suffocation in some patients when a facemask is used Facemasks also increase the possibility of swallowing air and aspiration if it cannot be readily removed If the mask can be readily removed and the patient is uncooperative there may be numerous periods when they do remove the mask If so they may experience transient periods of hypoxia and hypoventilation Lastly if the mask is too tight patient comfort will be compromised and skin ulcers may develop There is increased advancement relating to patient comfort and the ability to achieve a minimal leak system There are now many different types of masks designed for NIPSV One can choose the best type of mask to achieve adequate ventilation and oxygenation while allowing the patient to feel comfortable There are full face masks nasal masks nasal prongs and nasal pillows now available on the market from many manufacturers INDICATIONS FOR NIPSV assist control synchronized intermittent mandatory ventilation SIMV or other modes NIPSV should be considered useful ventilatory assistance rather than full ventilatory support Severely ill patients cannot be effectively managed with noninvasive ventilation NIPSV helps the patient breathe but does not provide life support Leaks are common and the mask can be dislodged or mal positioned which can be catastrophic if the patient becomes dependent upon NIPSV Nes is not a replacement for conventional ventilation i e in
16. decreases inspiratory work during the crisis Long Term Ventilation The phrase long term ventilation is used here to mean the patient s condition will not be reversed in a few hours or days NIPSV in some cases is used to satisfy the patient s wish not to be intubated Patients with severe chronic neurological dysfunction and terminal disease such as end stage COPD lung cancer end stage cystic fibrosis and human immunodeficiency virus HIV infection are potential candidates for NIPSV It is more comfortable and less costly than traditional ventilation and is a viable option for some of these patients Nocturnal Ventilation Some patients with less severe neuromuscular or musculoskeletal problems also benefit from NIPSV However these patients generally fall in the nocturnal ventilation category Ventilatory assistance during sleep relieves respiratory muscle fatigue that accumulates during waking hours This improves daytime functioning of the respiratory muscles 10 Chis material is copyrighted by RC Educational Consulting Services Jne Unauthorized duplication is prohibited by law Noninvasive PRESSURE SUPPORT VENTILATION Nasal and mask CPAP have been used for many years in the treatment of sleep apnea syndromes The addition of PSV allows for the relief of both obstructive and central sleep apnea symptoms In addition other conditions also benefit from nocturnal ventilatory assistance Patients with COPD and cystic fibro
17. e Unauthorized duplication is prohibited by law Noninvasive PRESSURE SUPPORT VENTILATION Practice Exercise Discussion ccccccccsseeccccessecccceussccccusecccceuseeccceusscceeuuesececauens 23 CONCLUSION sita 2 22 22 e ee ee Peet Bel et Poe St 23 SUGGESTED READING AND REFERENCES errar 24 Chis material is copyrighted by RC Educational Consulting Services Jne Unauthorized duplication is prohibited by law Noninvasive PRESSURE SUPPORT VENTILATION INTRODUCTION require a leak proof system to operate effectively This is achieved by intubation or a tight fitting facemask Intubation is invasive and very uncomfortable as are tightly fitted masks Leaks are also common with masks Mask continuous positive airway pressure CPAP systems have the same drawbacks Today those disadvantages are corrected Ni ventilation has been difficult to achieve in the past Conventional ventilators Noninvasive ventilation is the delivery of ventilatory support without the need for an invasive artificial airway Such ventilation has a role in the management of acute or chronic respiratory failure in many patients and may have a role for some patients with heart failure Noninvasive ventilation can often eliminate the need for intubation or tracheostomy and preserve normal swallowing speech and cough mechanisms The use of noninvasive positive pressure ventilation NPPV in acute hospital settings and at home has been steadily increasi
18. e IPAP PSV to achieve the lowest RR and least use of the accessory muscles Chis material is copyrighted by RC Educational Consulting Services Jne Unauthorized duplication is prohibited by law 23 Noninvasive PRESSURE SUPPORT VENTILATION SUGGESTED READING AND REFERENCES Boucher K 2005 Veteran Therapist Praises Non Invasive Ventilation Advance for Respiratory Care Practitioners Vol 18 Issue 4 Page 6 Chasens ER Ratcliffe SJ Weaver TE 2009 Development of the FOSQ 10 a short version of the functional outcomes of sleep questionnaire SLEEP 32 7 915 919 Chatmongkolchart S Kacmarek R amp Hess D 2001 March Heliox Delivery with Noninvasive Positive Pressure Ventilation A Laboratory Study Respiratory Care Journal 46 3 248 54 Donnellan M 2005 Avoiding Intubations Nobody Said It Would Be Easy to Cut Number of Invasively Ventilated Patients Advance for Respiratory Care Practitioners Vol 17 Issue 26 Page 21 Fernandez D 2004 Non Invasive Positive Pressure Ventilation Interface From Torture to Treatment Advance for Respiratory Care Practitioners Vol 17 Issue 19 Page 33 Gold W M Murray J F amp Nadel J A 2002 Atlas of Procedures in Respiratory Medicine WB Saunders Company Lewis S Heitkemper M Ruff Dirksen S Graber O Brien P amp Bucher L 2007 Medical Surgical Nursing Assessment and Management of Clinical Problems Elsevier Science Mason R J Broaddus V
19. e Visions can deliver a 100 O source gas The Visions provides leak compensation that is superior to the S T D and a nebulizer may be placed in line and has definite advantages Although flow characteristics may be affected the practitioner may consider using heliox via this mode of therapy for the patient in acute asthma exacerbation The National Association of Medical Directors of Respiratory Care NAMDRC site some specific indications to assist other physicians in determining which COPD patient is most likely to benefit from NIPSV Those with significant hypercapnea PaCO gt 55 those who desaturate at night SpO lt 88 for 5 continuous minutes during oxygen therapy of 2 L M and those who reported symptoms of fatigue dyspnea and morning headaches were sited by NAMDRC to benefit the most from NIPSV It is not unusual for the post op cardiac surgery patient to have bouts of fluid overload and pulmonary edema post extubation These are usually resolved quickly but the patient must be assisted for short periods NIPSV allows short term assistance noninvasively and is often administered to these patients Post extubation acute respiratory failure ARF is another indication for NIPSV Generally this is caused by a short term problem such as glottic edema laryngospasm or pulmonary edema NIPSV can mechanically dilate the airway until the problem spontaneously clears or vasoconstrictors and muscle relaxants become effective NIPSV also
20. e considerable fluctuation in tidal volume at a given NIPSV setting These patients are better suited for volume cycled ventilation Hyperventilating patients PaCO2 lt 35 mm Hg do not do as well on NIPSV as those with hypoventilation This may be related to inadequate flow from the NIPSV system being used Hyperventilating patients have a high minute volume demand that requires high flow rates This may not be possible with some noninvasive systems Patient anxiety in this population also may play a role in his her response It is of interest that patients with CO retention without major hypoxemia do better on NIPSV than those with major hypoxemia alone NIPSV is contraindicated in patients with no cough reflex and swallowing dysfunctions The patient must be able to adequately protect their airway since it won t be sealed with an artificial 12 Chis material is copyrighted by RC Educational Consulting Services Jne Unauthorized duplication is prohibited by law Noninvasive PRESSURE SUPPORT VENTILATION airway Excessive secretions that require frequent suctioning and the presence of upper GI bleeding also are contraindications A final obvious contraindication to NIPSV via nasal mask is obstruction of the nasopharyngeal airway Significant nasal resistance from obstruction limits the effectiveness of nasal ventilation This is of particular importance in the infant and pediatric populations where resistance is already high A facemask may
21. elief of dyspnea and use of the accessory muscles are some options Each will be described below Evaluation of the PaCO is the most accurate method of determining optimal IPAP ventilatory levels However it is invasive and costly Normal PaCO is 35 45 mm Hg Patients with COPD may have a normal PaCO higher than 45 mm Hg Patients with chronic restrictive Chis material is copyrighted by RC Educational Consulting Services Jne Unauthorized duplication is prohibited by law 17 Noninvasive PRESSURE SUPPORT VENTILATION pulmonary disease may have a normal PaCO lower than 35 mm Hg Adjust IPAP to return the patient to the PaCO providing a normal pH The PaCO providing a normal pH is an indicator of the patient s normal chronic ventilatory status This may be 40 mm Hg for those with normal lungs 50 mm Hg for those with COPD or 30 mm Hg for those with restrictive disease PETCO is far less accurate than PaCO and difficult to measure on non intubated patients Even under optimum conditions PETCO often does not correlate with PaCO The amount of CO exhaled is governed by several interrelated factors Changes in metabolic rate circulatory or ventilatory status will affect exhaled CO2 Exhaled CO is affected by production of CO by the tissues transportation of CO by the circulation and elimination of CO by ventilation Therefore interpretation of the PETCO requires a careful review of the overall metabolic circulatory and ventila
22. energy expenditure e improve lung volumes e nocturnal ventilation improve daytime functioning and activity level and intellectual capacity and decrease morning headache from CO retention and somnolence from lack of sleep during the night Intermittent Use NIPSV can be used as a treatment device in patients with an ineffective cough and poor Chis material is copyrighted by RC Educational Consulting Services Jne Unauthorized duplication is prohibited by law 11 Noninvasive PRESSURE SUPPORT VENTILATION inspiratory capacity Positive airway pressure mechanically dilates the airway getting air behind secretions and obstructions This enhances cough effectiveness If expiratory pressure is used there is improved aeration of poorly ventilated areas through the pores of Kohn This also improves cough effort and decreases atelectasis There is no evidence at the present time that NIPSV is more effective than conventional bronchial hygiene techniques CONTRAINDICATIONS require ventilation for life support are not candidates for NIPSV Such patients cannot tolerate an accidental disconnection or malposition of the mask Patients with severe cardiac arrhythmias or significant hypotension are also not candidates for NIPSV As with all positive pressure devices venous return and cardiac output may be decreased with NIPSV Additional contraindications to positive pressure ventilation such as bullous pulmonary disease and pneumothora
23. erbates this condition The tube also stimulates secretion production and interferes with the patient s ability to remove secretion increases airway resistance and increases the work of breathing Needless to say avoidance of intubation is a preferred option The result is a substantial decrease in cost and length of hospital stay The hospital stay decreases an average of 12 days for patients treated with noninvasive ventilation Patients experiencing residual post operative anesthesia and drug overdoses are candidates for NIPSV These patients require short term ventilation until the effects of the anesthesia drug have worn off Because they lack protection of their airway and are therefore susceptible to aspiration continuous monitoring of ventilator status must be provided to these patients Noninvasive ventilation has obvious advantages in this situation However protection of the airway is priority Patients who remain hypoxemic despite a high FIO delivered from various oxygen masks may benefit from NIPSV NIPSV helps overcome airway resistance and ease inspiratory workload It lowers the amount of pressure the patient needs to generate in order to achieve an adequate tidal volume VT Normally one must generate 1 cm H2O pressure to move 100 ml of air A 500 ml tidal volume is therefore generated with a pressure gradient of 5 cm H20 The pressure gradient needed for a given tidal volume increases proportionally with lung disease As a
24. for 10 15 minutes before attaching the head strap This allows the patient to become accustomed to the device Hold the mask in place as if one were providing an IPPB treatment During this time the practitioner is titrating ventilator settings to the most effective and comfortable for the patient More importantly the practitioner provides reassurance to the patient during this time while they get used to the mask Patient reassurance prevents many failures of noninvasive ventilation INITIAL VENTILATOR SETTINGS being used If one is merely trying to improve oxygenation or to treat obstructive sleep apnea OSA then continuous pressure CPAP alone may be sufficient If partial ventilatory support is necessary inspiratory pressure PSV must be provided The more severe the problem it becomes necessary to use the higher initial settings The first decision is to decide upon whether the use of CPAP or IPAP EPAP is chosen for the patient s condition initially The following are suggestions for the BiPAP ventilator in the acute care setting They are guidelines only institutional policy physician orders and the manufacturer s recommendations should be utilized for specific situations E settings depend upon the patient s condition the reason for NIPSV and the system 16 Chis material is copyrighted by RC Educational Consulting Services Jne Unauthorized duplication is prohibited by law Noninvasive PRESSURE SUPPORT VENTILATION I
25. ication is prohibited by law 5 Noninvasive PRESSURE SUPPORT VENTILATION This process is accomplished in a matter of microseconds providing a very stable pressure environment When the patient inhales the valve narrows closes and flow is increased to the patient When the patient ceases to inhale the valve widens opens and flow is decreased to the patient This allows pressure to drop to the expiratory level set The point of zero flow is the trigger between the expiratory and inspiratory phases Should a leak develop in the system the BiPAP Visions and S T D simply readjust flow to maintain the set pressures The system establishes a new baseline that takes into account the unintentional leak Therefore it compensates for the inevitable small leaks that occur from a noninvasive interface It is this unique ability to maintain pressures in the event of leaks that makes noninvasive ventilation with these ventilators more practical The popularity of the two Respironics ventilators virtually ensures that other ventilator manufacturers will develop leak compensation mechanisms in future designs For a more detailed description of the operation of the BiPAP Visions or S T D ventilators the reader is referred to the manufacturer s operating manual This course concentrates on the use of NIPSV in the acute care setting The Respironics systems in general are the most widely used so they will be used in examples Similar results are possible wi
26. irway or elastic resistance increases the pressure gradient needed to breath also increases To move the same volume of 500 ml it may take 10 20 or 30 cm H20 in the patient with lung disease NIPSV relieves the patient of having to generate the entire gradient by him herself Expiratory pressure with or without NIPSV recruits alveoli into gas exchange and increases functional residual capacity This further decreases the work of breathing by decreasing elastic resistance The result of decreased work decreased resistance and alveolar recruitment is improved oxygenation This allows FIO to be lowered into a less toxic range A lack of improvement in oxygenation and ventilation after 24 hours of NIPSV suggests intubation may be more appropriate Carbon monoxide poisoning has traditionally been treated with as close to 1 0 FIO as possible with a non rebreathing oxygen mask The Respironics Visions is capable of delivering the high FIO and providing PEEP and ventilation Using PEEP requires monitoring of the cardiac output to avoid decreased oxygen delivery to the tissues Decreasing O tissue delivery will Chis material is copyrighted by RC Educational Consulting Services Jne Unauthorized duplication is prohibited by law 9 Noninvasive PRESSURE SUPPORT VENTILATION compromise the treatment for carbon monoxide poisoning If conscious sedation of a patient has gone awry he she can benefit from short term oxygenation and ventilation Th
27. l time For example in 60 seconds a BPM of 20 means there are 3 seconds for inspiration and expiration An inspiratory time of 33 means 33 of 3 seconds 1 second is inspiration and 2 seconds are expiration An inspiratory time of 50 at 20 BPM gives 1 5 seconds inspiration and 1 5 seconds expiration Selection of an inspiratory time of 33 therefore provides an I E ratio of 1 2 50 gives a ratio of 1 1 Additional settings depend upon institutional care setting policy and physician order Patient disconnect and low pressure alarms must be set along with routine alarms such as heart rate percent of saturation etc MANAGEMENT AND MONITORING pressure levels accordingly Unlike volume cycled ventilation and intubation there are no guarantees with NIPSV Patient volumes can fluctuate significantly In the acute care setting this requires frequent adjustment of settings If oxygenation is low one has several options The first is simply to check for leaks in the system Following that FIO gt liter flow can be increased or EPAP CPAP can be increased A greater tidal volume via an increase in IPAP PSV or an increase in the breaths per minute may also improve oxygenation Msi of NIPSV consists of monitoring the patient s response and titrating Conversely a decrease in EPAP CPAP improves oxygenation if over distention is suspected Over distention from excessive expiratory pressure can decrease pulmonary blood flow This lowers oxygenation
28. lting Services Inc wishes to provide our customers with the highest quality continuing education materials possible Your honest feedback will help us to continually improve our courses and meet state regulations Responses to the following evaluation questions should be recorded in the far right hand column of the FasTrax answer sheet in the section marked Evaluation Mark A for Yes and B for No Thank you YES NO 1 Were the objectives of the course met 2 Was the material presented in a clear and understandable manner 3 Was the material well organized 4 Was the content presented without bias of any commercial product or drug 5 Was the material relevant to your job 6 Did you learn something new 7 Was the material interesting 8 Were the illustrations if any helpful 9 Would you recommend this course to a friend 30 Chis material is copyrighted by RC Educational Consulting Services Jne Unauthorized duplication is prohibited by law
29. n the management of acute respiratory insufficiency impending respiratory failure one manufacturer recommends the initial settings of S T mode IPAP EPAP of 10 4 backup rate of 4 to 8 depending on the patient s spontaneous rate and rise time adjusted to patient comfort The BiPAP ventilator is a continuous flow device providing two levels of positive pressure The EPAP setting determines the lower pressure level the IPAP setting determines the upper pressure level In CPAP mode only one level is provided The difference between the two levels is what determines actual ventilating PSV pressure EPAP is therefore analogous to PEEP and IPAP analogous to PSV on conventional ventilators Pressure within the circuit oscillates between IPAP and EPAP on inspiration and expiration The initial CPAP setting is usually 5 cm H20 The initial EPAP setting is usually 3 to 5 cm H20 These are increased in 1 2 cm increments to achieve the desired clinical response Desired clinical response may be the lowest RR saturation gt 90 Dat gt 60 mm Hg no apneic periods least use of the accessory muscles or others Oximetry and ABG response are the most common tools to evaluate EPAP CPAP settings EPAP and CPAP prevent premature alveolar and small airway collapse and reopen previously collapsed alveoli The result of alveolar recruitment and prevention of collapse is improved oxygenation Oximetry and PaO should increase accordingly In some systems ox
30. ng This is possible due to continued development of new noninvasive ventilators and improved patient interfaces Ventilators Used for Noninvasive Positive Pressure Ventilation In recent years improved ventilator and mask designs have made noninvasive ventilation more practical Ventilators such as the Respironics BiPAP Vision and S T D Respironics Corp have leak compensation mechanisms Ventilating pressures can therefore be achieved and maintained without an absolutely leak proof system Leak compensation also allows for a looser and more comfortable fit Figure 1 illustrates examples of noninvasive ventilation systems Figure 1 NONINVASIVE VENTILATION SYSTEMS BiPAP Pro 2 without Humidifier BiPAP Pro 2 with Humidifier 4 Chis material is copyrighted by RC Educational Consulting Services Jne Unauthorized duplication is prohibited by law Noninvasive PRESSURE SUPPORT VENTILATION Used In Home Care E BiPAP Vision BiPAP S T D The same manufacturer produces a nasal mask for use with the BiPAP S T D and Vision ventilators It is easier to maintain a seal with the nasal mask than a conventional facemask The patient is also able to talk eat and drink with the nasal mask in place This enhances patient comfort and compliance considerably BiPAP therapy may be used in many locations to describe noninvasive pressure support ventilation NIPSV combined with expiratory positive airway pressure EPAP regardless of
31. o ce S T mode IPAP EPAP of 10 4 backup rate of 4 8 BPM allofthe above none ofthe above The main difference between the Visions and the S T D BiPAP models is that 20 ce The Visions can deliver 1 0 FIO The practitioner can choose the mode of ventilation The practitioner can choose the respiratory rate The S T D can be used for patients in respiratory arrest A patient whose diagnosis is LEAST LIKELY to require long term NIPSV is one with ao co Chis materi end stage cystic fibrosis post polio syndrome congestive heart failure lung cancer al is copyrighted by RC Educational Consulting Services Inc Unauthorized duplication is prohibited by law Noninvasive PRESSURE SUPPORT VENTILATION 14 A patient whose diagnosis will MOST LIKELY require long term NIPSV is one with a acute respiratory failure b quadriplegia c post op coronary artery bypass graph d drug overdose 15 Which statement s regarding CPAP and NIPSV is are MOST TRUE CPAP is generally used during the night for obstructive sleep apnea NIPSV may be used during sleep for those with neuromuscular disorders CPAP is the best choice for treating acute respiratory failure a amp b a amp c oro CP Chis material is copyrighted by RC Educational Consulting Services Jne Unauthorized duplication is prohibited by law 29 Noninvasive PRESSURE SUPPORT VENTILATION COURSE EVALUATION RC Educational Consu
32. piratory failure e post op cardiac surgery e congestive heart failure CHF fluid overload amp pulmonary edema e restrictive disorders chest wall restriction such as kyphoscoliosis and severe obesity e to relieve respiratory muscle fatigue e to decrease work of breathing e do not intubate orders e nocturnal hypoventilation e as a weaning strategy Short Term Ventilation Patients in CHF generally need ventilator assistance until diuretic and inotropic medications become effective In these patients EPAP maintains alveolar and airway patency and inspiratory PSV decreases the work of breathing The application of intrathoracic positive pressure also reduces venous return and lowers ventricular preload This lowers congestion aids contraction 8 Chis material is copyrighted by RC Educational Consulting Services Jne Unauthorized duplication is prohibited by law Noninvasive PRESSURE SUPPORT VENTILATION and eases the cardiac workload of the heart Therefore NIPSV and EPAP lower both circulatory and ventilatory work The added benefit of oxygen up to 100 when needed assists in decreasing cardiac work reducing tissue hypoxia and decreasing work of breathing Patients with an acute exacerbation of COPD require short term NIPSV until medications antibiotics bronchodilators corticosteroids and mucolytics become effective COPD patients already have hyper reactive airways Introduction of an endotracheal tube during a crisis exac
33. pm compensated pH gt 7 35 SpO gt 90 on lt or 3 lpm O TABLE 3 Noninvasive Positive Pressure Ventilator Adjustments Setting Adjustment Anticipated Result IPAP Increase Increased tidal volume increase ventilation decrease PaCO Decrease Decreased tidal volume decrease ventilation increase PaCO EPAP Increase Increased FRC increased PaO decrease tidal volume improved synchronization if intrinsic PEEP is present Decrease Decrease FRC decrease PaO increase tidal volume possible rebreathing of CO if EPAP lt 4 cm H20 FIO Increase Increase PaO Possible oral and nasal drying due to high flow of titrated O or high FIO Decrease Decrease PaO Rate control Increase Increased minute volume in timed modes decrease PaCO Decrease Decreased minute volume in timed modes increase PaCO Chis material is copyrighted by RC Educational Consulting Services Jne Unauthorized duplication is prohibited by law 21 Noninvasive PRESSURE SUPPORT VENTILATION TABLE 4 CLINICAL PRACTICE EXERCISE The following practice exercise is discussed below 1 The patient is a 67 year old male admitted for shortness of breath He has mild COPD He is complaining of dyspnea heart rate is 140 RR is 32 and BP is 150 120 Crackles are heard bilaterally Oximetry is 85 on room air Evaluate this information and make recommendations 2 A chest X ray reveals perihilar fluffy infiltrate
34. pper lip A spacer or forehead bumper is provided to be placed between the mask and the patient s forehead which improves the seal and patient comfort and often is adjustable for a custom fit If excessive pressure is required to seal a mask you probably do not have the correct mask size Understand the needs of the patient through leading questions to include or eliminate certain types of mask interfaces Respironics and other manufacturers now have many types of masks total facemasks full face masks nasal masks and direct nasal pillow prong type masks Sizing and selection is now easier and more accurate than ever Once the mask has been selected attach the head strap to the mask Place the mask on the patient and tighten the head strap Tighten the straps until all significant leaks are eliminated and pressure from the straps is equally applied at all points of attachment harness The BiPAP ventilator compensates for small leaks so the mask need not be absolutely pressure tight Other systems ventilators used for NIPSV may require a tighter fit so there is no leak Consult the operating manual regarding leak compensation for the system being used Regardless of the system being used have the patient move their head around in a normal range of motion after tightening the straps Confirm the seal and position of the mask during and after movement In some patients particularly those who are anxious it may be wise to hold the mask in place
35. re titration of pressure levels Institutional care setting policy also determines the amount of monitoring to be performed The more critical the patient the more extensive the monitoring is necessary Obviously ventilatory parameters FIOy liter flow and vital signs will be monitored Ventilatory parameters to monitor are mode IPAP and EPAP setting PSV level IPAP EPAP percent inspiratory time percent IPAP set and spontaneous RR high and low pressure alarm settings estimated tidal volume and leak The practitioner may note mask and spacer size and comment on skin integrity under the mask Breath sounds and oximetry are other standard monitoring parameters Baseline and periodic ABGs are wise Oximetry and ETCO gt monitoring drastically reduce the number of ABGs necessary Observation and palpation of the accessory muscles is another useful monitoring 20 Chis material is copyrighted by RC Educational Consulting Services Jne Unauthorized duplication is prohibited by law Noninvasive PRESSURE SUPPORT VENTILATION parameter Monitoring of RR via the vital signs is one of the most helpful monitoring tools since it is an indicator of patient work of breathing TO OPTIMIZE PATIENT VENTILATOR SYNCHRONY optimize tidal volume and or PaCO minimize accessory muscle use alleviate dyspnea decrease respiratory rate WEANING CRITERIA e respiratory rate lt 24 BPM clinically stable for gt 6 hours e heart rate lt 110 b
36. s an enlarged heart and prominent vascular markings An ABG reveals pH 7 32 Pa0 50 mm Hg PaCO 60 mm Hg HCO3 30 mEq L and 80 saturation on 3 lpm nasal cannula The patient appears fatigued and chest movement has decreased What are your suggestions and why 3 The physician agrees with your suggestions What are the initial settings for this patient 4 Upon implementation the patient s RR decreases to 24 and oximetry increases to 85 Evaluate this information and make recommendations 22 Chis material is copyrighted by RC Educational Consulting Services Inc Unauthorized duplication is prohibited by law Noninvasive PRESSURE SUPPORT VENTILATION Practice Exercise Discussion 1 Based upon the patient s complaints and vital signs he is in acute distress Bilateral crackles may be bilateral pneumonia bronchitis or pulmonary edema Oximetry indicates hypoxia At this point oxygen ABGs and a chest X ray are indicated 2 The chest X ray is compatible with CHF ABGs reveal hypoxia and mild for this patient hypoventilation The patient appears to be entering respiratory failure Suggest diuretics and inotropics for the CHF Suggest NIPSV with EPAP for hypoventilation and hypoxia 3 Set IPAP PSV to 8 0 5 0 cm H20 EPAP PEEP to 3 0 cm H20 FIO to 3 lpm or 30 40 The patient is spontaneously breathing so setting a mechanical BPM isn t necessary A back up rate can be used if desired 4
37. sis who are placed on nocturnal ventilation have improved daytime symptoms Patients with restrictive pulmonary disease such as kyphoscoliosis report the same results All patients suffer a slight drop in oxygenation and rise in CO when they are asleep For most patients these changes are insignificant However they are significant for patients with borderline pulmonary status Significant fluctuations of blood gases disrupt normal sleep patterns Nocturnal NIPSV prevents these fluctuations in ventilatory status and improves sleep patterns This in turn improves daytime endurance of the patient Nocturnal NIPSV unloads respiratory muscles from the work they have done during the day Patients with pulmonary disease must work harder throughout the day to breathe Fatigue accumulates in the muscles during the waking hours because of the increased work of breathing Resting the muscles at night through NIPSV relieves this fatigue The result of nocturnal relief is greater daytime efficiency of the muscle There is an increase in PaO and decrease in daytime PaCO following nocturnal ventilation Patients also report less dyspnea and fewer morning headaches following nocturnal ventilation Beneficial Effects of NIPSV e avoid the need for tracheostomy e lessen the incidence of nocturnal desaturation e improve blood gases and gas exchange e improve respiratory muscle strength and endurance e decrease inspiratory muscle fatigue by decreasing muscle
38. th other ventilators using other terminology For example inspiratory positive irway Pressure IPAP on the BiPAP ventilator may be pressure support ventilation PSV on others Expiratory positive airway pressure EPAP on the BiPAP is similar to positive end expiratory pressure PEEP on another ventilator Continuous positive airway pressure CPAP on the BiPAP ventilator differs little from other CPAP devices except for leak compensation Please note the mechanism various ventilators or systems use to provide IPAP PSV EPAP CPAP and PEEP may differ considerably A firm understanding of both the patient s condition and the equipment being used will dictate what is the appropriate ventilator terminology or system for a given patient A simplified comparison of the Respironics ST D and Visions ventilators is shown in Table 1 Table 1 SIMPLIFIED COMPARISON OF THE RESPIRONICS ST D AND VISIONS VENTILATORS ST D VISIONS IPAP 4 30 cm H20 IPAP 4 40 cm HO EPAP 4 15 cm H20 EPAP 4 20 cm H20 Oxygen source bleed in Oxygen source internal module blended VT accuracy 15 VT accuracy 10 Monitors VT amp patient leak Expanded monitoring VE PIP RR Ti Tiot pt triggered breaths Limited alarms Hi Lo pressure Expanded alarms apnea VE high rate low rate No graphics Waveforms and Bar Graphs Modes CPAP spontaneous Modes CPAP and spontaneous timed spontaneous timed timed 6 Chis m
39. tory status of the patient However it is useful for trend monitoring and detection of gross changes in ventilatory status PETCO is not recommended for determination of initial settings It is more useful for monitoring the patient following initial setup Monitoring of RR is the simplest and possibly the most effective method of determining IPAP levels RR correlates well with work of breathing and degree of respiratory distress If a patient has a high RR in most patients it generally means there is greater work of breathing or distress Conversely when work or distress decrease RR also decreases Adjust initial IPAP levels to achieve the lowest normal RR possible without abolishing the patient s ventilatory drive Use of the accessory muscles is another good indicator of work of breathing and respiratory distress It s shown the greater the work or distress the more muscle use is evident Therefore observation and palpation of the accessory muscles can be a useful indicator of the patient s work of breathing Adjust initial IPAP levels to achieve the least use of the accessory muscles Patient subjective relief of dyspnea should also be considered when setting the initial IPAP level In an alert patient subjective relief is possibly the most important determinant of ventilator settings The patient knows what his her body feels like and with noninvasive ventilation the patient can relay those feelings to the practitioner This is a
40. tubation and the use of NIPSV can be used for short term long term or nocturnal ventilation It also can be used as an intermittent treatment for pulmonary hygiene similar to intermittent positive pressure breathing Chis material is copyrighted by RC Educational Consulting Services Jne Unauthorized duplication is prohibited by law 7 Noninvasive PRESSURE SUPPORT VENTILATION IPPB or positive expiratory pressure PEP therapy Periodic usage is another application to help the patient rest in cases of respiratory insufficiency and increased work of breathing Examples are neuromuscular disorders muscular dystrophy or amyotrophic lateral sclerosis ALS and severe chronic obstructive pulmonary disease COPD These patients can benefit from using NIPSV a few hours during the day and while they sleep which helps to expel excess carbon dioxide that builds up from hypoventilation Specific NIPSV criteria are not delineated at the present time The following material should be considered guidelines only NIPSV is indicated for patients with intact respiratory drives who need only partial ventilatory support e neuromuscular disorders Muscular dystrophy spinal cord injuries idiopathic hypoventilation syndrome post polio respiratory insufficiency ALS or other neuromuscular diseases e obstructive disorders acute exacerbation of COPD end stage cystic fibrosis e residual post op anesthesia e drug overdose e post extubation acute res
41. unique concept to practitioners accustomed to nonverbal intubated ventilator patients Adjustment of IPAP to achieve a specific tidal volume is difficult and not recommended Patient tidal volume varies on NIPSV depending upon inspiratory effort patient position inspiratory flow and other factors To try and maintain an exact tidal volume is difficult under such conditions However one can trend changes in tidal volume achieved and set a goal range of tidal volumes that are consistent with adequate ventilation for the patient Generally an increase in IPAP will help the patient increase tidal volumes decrease work of breathing and decrease PaCO There are three modes of operation to choose from on the BiPAP ventilator spontaneous spontaneous timed and timed It is very important to select one of these modes if you wish the patient to receive bilevel positive pressure If the selection switch is left on IPAP the patient will receive IPAP only If the selection switch is left on EPAP CPAP the patient will receive CPAP only Selecting one of the following modes tells the ventilator to provide bi level pressures 18 Chis material is copyrighted by RC Educational Consulting Services Jne Unauthorized duplication is prohibited by law Noninvasive PRESSURE SUPPORT VENTILATION Spontaneous is what the term implies spontaneous breathing If the patient does not trigger the ventilator through spontaneous inspiratory effort no NIPSV breaths are
42. x also apply to NIPSV N IPSV should not be used in several situations conditions see Table 2 Patients who Acute facial trauma and basilar skull fractures are contraindications In trauma patients an adequate seal cannot be obtained and the mask will be too painful for the patient Skull fractures may lead to pneumocephalus if air dissects between the tissues Generally patients should be awake and cooperative for NIPSV However sleep is not an absolute contraindication since many patients benefit from nocturnal ventilation Severe dementia is an absolute contraindication Very confused or combative patients who cannot or will not follow commands are not candidates for NIPSV Patients requiring high ventilating pressures are a relative contraindication Ventilating pressures greater than 30 cm H20 are difficult to obtain with a noninvasive system High ventilating pressures are also an indicator of severe disease These patients are probably better treated by intubation and conventional ventilation High FIO is also difficult to achieve with some noninvasive systems Noninvasive monitoring of FIO is difficult and variable in most systems Keep in mind that NIPSV may allow FIO to be lowered in some patients If the patient remains hypoxic on NIPSV intubation would be inevitable Tidal volume varies on NIPSV depending upon the patients inspiratory effort and pulmonary mechanics Patients with rapidly changing pulmonary compliance hav
43. ygen must be fed into the BiPAP system via O supply tubing Therefore in these cases FIO can be difficult to achieve or maintain Begin with a flow rate of 2 5 litres per minute lpm and adjust according to relief of patient symptoms and acceptable oximetry values Bleed in oxygen flow rates gt 10 12 lpm may indicate another mode of therapy or intubation may be necessary In systems such as the Visions the practitioner may set an exact FIO The initial IPAP setting begins at about 5 cm H20 above the initial EPAP setting This is 8 0 cm H20 on the BiPAP ventilator if the initial EPAP is 3 0 cm HO On most ventilators the PSV setting automatically takes into account any expiratory pressure setting This is known as PEEP compensation The BiPAP ventilator is not PEEP compensated If you want the patient to receive x amount of PSV add x to the EPAP level for the initial IPAP setting So an initial EPAP of 3 cm H20 plus PSV of 5 cm H20 IPAP of 8 cm HO If the system being used is PEEP compensated set initial inspiratory pressure at 5 0 cm H20 The peak pressure can be observed on the manometer The peak pressure is important to monitor and helps the practitioner determine if the device is PEEP compensated or not IPAP is usually increased in 2 cm increments to achieve the desired clinical response As with EPAP the desired clinical response can be evaluated many ways Evaluation of PaCO PETCO RR tidal volume subjective r
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