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Bipap

Non-invasive ventilation (NIV) provides ventilatory support without intubation by delivering positive airway pressure via a face or nasal mask. NIV can benefit patients with respiratory failure, acute pulmonary edema, or exacerbations of COPD or asthma. It is less invasive than endotracheal intubation and reduces complications. NIV modes include CPAP, which improves oxygenation, and bi-level positive airway pressure (BiPAP), which can also improve ventilation and lower carbon dioxide levels. Close monitoring is needed to assess response and determine if intubation is required if the patient does not improve or deteriorates on NIV.

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Tnem Nat
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120 views

Bipap

Non-invasive ventilation (NIV) provides ventilatory support without intubation by delivering positive airway pressure via a face or nasal mask. NIV can benefit patients with respiratory failure, acute pulmonary edema, or exacerbations of COPD or asthma. It is less invasive than endotracheal intubation and reduces complications. NIV modes include CPAP, which improves oxygenation, and bi-level positive airway pressure (BiPAP), which can also improve ventilation and lower carbon dioxide levels. Close monitoring is needed to assess response and determine if intubation is required if the patient does not improve or deteriorates on NIV.

Uploaded by

Tnem Nat
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© © All Rights Reserved
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Download as PDF, TXT or read online on Scribd
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Non Invasive Ventilation

Linda Grady
Clinical Nurse Specialist
2010

Non-Invasive Ventilation (NIV)


Technique that provides and enhances
alveolar ventilation without the use of
an endotracheal intubation

Who May Benefit?


CPAP - Patients with a reduced Functional Residual
Capacity (FRC) may benefit from CPAP
therapy.
- Type I Respiratory Failure
failure to maintain PaO2
-

Acute LVF needs PEEP

BiPAP Type I Respiratory Failure where patients


are tiring PaC02 TV LOC
- Type II acute episode of COPD patient

CPAP vs BiLevel
CPAP

Bilevel

Used to improve PaO2


Reduce WOB
- FRC
- Alveoli ventilation
- Offset intrinsic PEEP

Used to improve ABG


Reduce WOB
- TV
- MV while RR
- PaCO2 SaO2 Pa02
- Plus CPAP benefits

Hypoxemia

Hypercapnia

So Why NIV & not ETT?


Less invasive reduce patient discomfort,
anxiety and sedation
Reduced complications - cardiac output,
aspiration, pneumonia, pneumothorax,
bronchospasm, and trauma
Preservation of speech and swallowing
function
Preservation of airway defence mechanisms
Feel more involved and in control of their
treatment
Reduce time spent in ICU use outside ICU

The patient has...


An intact respiratory drive
A patent airway
Intact gag & cough reflexes

The ability to clear


secretions

Caution
with..
The patient has a
reduced level of
consciousness
Is confused

Has emphysema
Has facial or
head injuries
Would you use NIV on a
patient who is dying?

Nasal

CPAP -FACIAL

Full face

NIV via Tracheostomy

BiPAP, BiLevel, Biphasic,


Uses Inspiratory pressure
IPAP
Uses expiration pressure
EPAP
Pressure support
IPAP EPAP = PPS
Supports spontaneous ventilation
IPAP : augments inspiratory efforts
EPAP: CPAP
Rise Time: Rate at which machine increase airway
pressure from EPAP to IPAP

Ventilation Use in the ICU


Pre NON Invasive ventilators
Intubation hours 4oo,ooo hrs /yr
Post
Intubation hours 175,ooo hrs/yr
Non Invasive Vent 75o,ooohrs/yr

Initiating NIV
Need to ask:
What are we trying to achieve for this patient ?
& Can we do it with this device?

Consider: Underlying pathophysiology


Can the patient tolerate it
Time of day

Not isolated treatment


Oxygen therapy
Nebulised Bronchodilators
Corticosteroids
Aminophylline, antibiotics
Respiratory Consultants
PLAN - include patient

Setting initial pressures


Mode : Spontaneous
IPAP: 12-14cmH20
EPAP : 6-8cmH20
Mask : Face
Oxygen: to titrate SaO2 88-92%

Increase IPAP to
increase TV

Increase EPAP if
ineffective effort
noted

Increase FiO2 if SaO2


low and increase EPAP

Change to nasal mask if


more comfortable

IPAP
Inspiratory Positive Airway Pressure
BiPAP senses when an inspiratory effort is being made
and delivers a flow to the pre set pressure
Flow stops when the pressure is reached
Dependent on compliance and resistance
Expiration is passive
What do you set the IPAP on?
Start safe 12cm H20 watch!!
Reassess

EPAP
Expiratory Positive Airway Pressure
Positive pressure applied to end expiration

EPAP does all the positive elements that PEEP does


What do you set EPAP on ?
Start safe

6cm H20

watch!!

Reassess

PPS
Positive Pressure Support
Assists spontaneous respiration ( TV)
Higher PPS
Greater the support
IPAP EPAP =PPS
e.g. 14-6= 8 PPS
Inspiratory time individual

Improvement in ABGs and Clinical Condition

NO
Check leaks
IPAP 20cmH20
EPAP to 10cm H20
02 aim Sa02 >90%
Talk with Resp or ICU Consultant
Consider need for intubation &
mechanical ventilation.
or DNR

YES
Continue mask ventilation,
intermittent periods off NIV
to gauge response.
Taper to met patients' needs
2hours off 4 hours on
Withdrawal of NIV

Adverse Effects of NIV


Pressure areas, skin necrosis (duoderm)
Air swallowing & gastric distension
vomiting & aspiration! N/G
Dry eye & oral mucous membranes
Discomfort, anxiety
Where are these patients???
Contract with patient for regular breaks if
condition allows.

When do we use it?


Hypercapnia COPD exacerbation, OD
Hypoxemia Pneumonia, ALI, ARDS
Immunocompromised
Acute Pulmonary Oedema
Obese
Weaning
Post op respiratory failure
Post extubation
DNR status

The Plan....

Patient selection. Discuss with family & patient prior


to event or need for it (COPD)
..stay and play or scoop and go?...
Early discussion with ICU & transport team
Have a plan for use of NIV in your area prior to use
..discuss with respiratory team
Liaise with base hospital
How long are you going to persevere..
What is your ceiling...

Doesnt replace..
Sound

clinical judgement
Need for immediate intubation

When not to use it?

When is enough.enough

Clinical deterioration RR WOB SOB


No improvement or worsening gas exchange
pH CO2
Haemodynamic instability
Need for ETT to protect airway
Failure to improve mental status in patients
who are lethargic from CO2 retention
Inability to tolerate the mask

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