I. Subject: Pressure Support Ventilation (PSV) with BiPAP Device/Nasal CPAP

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1 I. Subject: Pressure Support Ventilation (PSV) with BiPAP Device/Nasal CPAP II. Policy: PSV with BiPAP device/nasal CPAP will be initiated upon a physician's order by Respiratory Therapy personnel trained in the techniques of mechanical ventilatory support. III. Indications: A. Spontaneously breathing patients who exhibit acute alveolar hypoventilation. B. Patients with chronic ventilatory muscular dysfunction, those who exhibit clinical evidence of ventilatory muscle fatigue, or those likely to develop the above. C. Patients with refractory hypoxemia. D. Patients with upper airway obstructions due to such conditions as laryngeal/supra or sub-glottic edema in the post-extubation period or after inhalational injury, strictures of the extra thoracic trachea, or obstructing tracheal or glottic lesions in whom it is desirable to avoid endotracheal intubation. E. Patients with severe chest wall disease. F. Obstructive Sleep Apnea or combined obstructive and central sleep apnea. IV. Contraindications and Relative Contraindications: A. Patients incapable of maintaining life sustaining ventilation in the event of malposition of the mask. B. History of allergy or hypersensitivity to the mask material where the allergic reaction outweighs the benefit of ventilatory assistance, and the application of the mask to those susceptible to pressure sores where this outweighs the benefit of ventilatory assistance. C. Although the risk is small, caution must be exercised in administration by a full face mask because of the possibility of gastric distension and/or aspiration of gastric contents. In these patients placement of a nasogastric tube at suction may be advisable. D. Hypotension induced by positive pressure ventilation E. Patients with or susceptible to pneumothorax or pneumomediastinum as in p atients with pre-existing bullous lung disease. 1

2 F. Worsening of V/Q relationships with subsequent hypoxemia and hypercarbia is possible especially in patients with COPD. G. Patient with copious secretions, especially those who may require suctioning. H. Comatose or semi-comatose patients and others lacking normal airway protective mechanisms. V. Rationale: Nasal CPAP is a major non-pharmacologic treatment of obstructive sleep apnea. Nasal CPAP has replaced tracheostomy as the preferred mode of therapy in moderate or severe forms of the disease. This method uses a soft occlusive nasal mask held to the face by straps, an expiratory value and tubing, and a blower system to provide continuous positive pressure which typically ranges from 2.5 to 15 cm H2O. Nasal CPAP works in obstructive apnea by providing a pneumatic splint forcing the soft palate and the base of the tongue forward preventing airway collapse. A few reports claim effectiveness for central sleep apnea as well. Nasal CPAP has also been employed at low levels (5 cm H2O) as a mechanical aid to COPD patients who are in acute respiratory failure in order to avoid mechanical ventilation. The use of external PEEP at a level sufficient to overcome auto-peep decreases the work of breathing in these patients. Recently, the development of a method of delivering Pressure Support Ventilation with the BiPAP ventilatory support system has provided assisted ventilation with a nasal or full face mask. The BiPAP unit is similar to a standard CPAP generator with the addition of a pressure controlling valve which maintains pressure at one of two different levels, the expiratory positive airway pressure (EPAP) level (equivalent to PEEP of conventional ventilations) or the inspiratory positive airway pressure (IPAP) level (equivalent to pressure support), even in the presence of rapidly changing flows. In its spontaneousmode setting, the unit will cycle from EPAP to IPAP when the patient's inspiratory flow exceeds 40 ml/s for more than 30 ms. The IPAP level is maintained for more than 180 ms and will return to EPAP when: (1) the inspiratory flow decreases below a threshold level, or (2) an active expiratory effort is detected, or (3) IPAP has lasted 3 sec. The timed mode allows time cycling of the unit at a user designated interval and pre-set inspiratory time. The spontaneous/ timed mode allows a combination of both modes in which machine generated breaths are delivered when the patient's respiratory rate falls below a set level. This bi-level nasal CPAP has proved useful in proving positive-pressure ventilatory assistance in patients with neuromuscular disorders, spinal cord injuries, and chest wall diseases, and particularly in the nocturnal support of these patients. Bi-level nasal CPAP has also been used with some success in COPD patients in acute hypercapnic ventilatory failure. 2

3 VI. Materials: A. BiPAP machine B. BiPAP circuit C. Airway pressure monitoring line D. Nasal mask or full face mask with head strap E. Humidifier F. Supplemental oxygen input adaptor (if needed) VII. Procedure: A. Check order: Compare the requisition with the physician's order to ensure that no discrepancies exist. B. Review Chart: On the patient's chart identify all pertinent data in the following areas: History and physical, admitting diagnosis, progress notes, arterial blood gas analysis, and chest x-rays. Based on the patient data, identify the following: 1) Conditions that indicate the need for CPAP or PSV. 2) Potential hazards of CPAP or PSV for the patient C. Maintain Asepsis: While performing the remainder of this procedure, it is expected that asepsis will be maintained. This includes washing hands before, after and at any time contamination is suspected. D. Obtain equipment: Collect the equipment and supplies as mentioned in item VI above. E. Assemble equipment: 1. Attach small bore tubing supplied between BiPAP unit outlet and humidifier canister inlet port. 2. Attach humidifier canister to heater. Do not turn heater on. 3. Attach BiPAP circuit to the outlet port of the humidifier making sure not to cover the vent hole at the distal end of the tubing 3

4 4. Attach the airway pressure monitoring tubing to the BiPAP unit, the pressure monitor (certain models), and to the port at the distal end of the circuit. 5. Select the proper size of nasal or face mask. Use the smallest size mask that will comfortably fit the patient and provide a good seal. Mask sizing gauges for both nasal and full face masks are available to assist in initial selection. Be sure the nasal mask fits from the end of the nasal bone to just below the nares. To prevent abrasion, a patch of wound care duoderm dressing may be placed on the bridge of the nose. Care should be taken to assure that the mask does not fit too tightly and produce pressure sores. A small leak is desirable and, as a general rule two fingers should fit between the mask and the patient s face. 6. Attach the mask to the BiPAP circuit. F. Confirm patient: Ensure that the procedure is performed with the correct patient. G. Inform patient: Interact with the patient as follows: 1. Introduce yourself by name and department, if not already acquainted. 2. Tell the patient what procedure is to be performed. 3. Explain the procedure by describing: a. What is to be performed. b. How it is to be performed. c. What the patient is expected to do. d. What you will be doing. e. How frequently it will be performed. H. Implement procedure: 1. Set the initial mode, IPAP, EPAP settings, FIO2, and rate as prescribed by the physician, or as clinically indicated. It is often helpful to start with lower setting until the patient is comfortable with the support and then move up to optimal settings. The following initial settings are suggested: 4

5 a. IPAP- 8.0 cm, H2O b. EPAP- 3.0 cm, H2O c. Check mask pressure with in-line manometer or by activating the pressure display on he BiPAP Detachable Control Panel. d. FIO2- Match current administration. In newer systems, FIO2 may be set. Monitor FIO2 with an in-line analyzer. In older systems, precise control of FIO2 is difficult to achieve with the BiPAP system. In older systems, bleed in oxygen at the mask port. Start with 2 to 5 L/min and monitor the patient for adequate oxygenation. Adjust liter flow as necessary. Anytime the IPAP and EPAP settings are adjusted, the oxygen flow should be evaluated. Use of an in-line oxygen analyzer may not adequately reflect the delivered FIO2 due to analyzer response time and gas mixing in the patient circuit. Therefore,the patient's oxygenation should be evaluated to determine supplemental oxygen requirements. A pulse oximeter should be used to continuously monitor adequacy of oxygenation. e.. BiPAP MODE-as clinically indicated: -Spontaneous Set IPAP and EPAP per above. -Spontaneous/Timed Set IPAP and EPAP per above. Set BPM as clinically indicated. Consider 2-5 breaths/min less than the patient's spontaneous Rate. Set rise time (if available) to better synchronize flow delivery to patient demand. Be cautious not to set a rise time less than total spontaneous I time in pediatric patients. -Timed Set BPM as clinically indicated. Consider setting slightly higher than the patient's spontaneous rate. Set % IPAP as clinically indicated. (older models) Consider setting 33%-50% to deliver a 1:2 to 1:1 I:E ratio. Set I time (newer models) (typically sec in adult) 2. Apply nasal mask to the patient's nose or apply face mask. Select proper spacer size and attach spacer to nasal mask. It is often helpful to hold mask on patient initially to show that the mask can come off if necessary and to build patient confidence. 3. Attach head strap to mask. Apply mask and head strap to patient. Adjust straps. Some leak is acceptable. Avoid over-tightening. 4. Set high pressure alarm on pressure monitor appropriately, usually about 5 cm H2O above IPAP setting. Set low pressure alarm appropriately, 5

6 usually about 2 cm H2O below EPAP setting. Set additional alarms as indicated. 5. Monitor clinical and physiological parameters, which may include: a. ABG's b. Pulse and respiratory rate. c. Skin color, temperature, and perfusion. d. Use of accessory muscles of ventilation. f. Breath sounds. 6. Re-adjust BiPAP settings as indicated based on patient response, comfort, and clinical and laboratory findings. a. IPAP: b. EPAP: Increase IPAP in increments of 2.0 cmh2o to increase "pressure boost" to reduce or stabilize PaCO2 with augmentation of alveolar ventilation, relieve the sense of dyspnea, reduce the use of accessory muscles of ventilation and eliminate stridor if present. An estimated tidal volume is displayed and may be used to set IPAP level. A tidal volume goal is normally between 4-8 cc/kg ideal body weight. Increase EPAP by cm H2O increments to increase Functional Residual Capacity (FRC) and improve oxygenation in those patients with low pulmonary compliance and shunting, or to manage upper airway obstruction. It is not possible (or desirable) to raise the EPAP levels higher than IPAP. c. AVAPS (optional) Set targeted tidal volume and minimum and maximum allowable pressure to achieve desired average tidal volume. VIII. Special Considerations: A. Nasal pillows may be used in place of a nasal mask. The nasal pillows should be sized to obtain a seal in each nare. The pillows holder is secured to a special head strap. B. There is the potential for CO2 rebreathing in patients with low minute ventilation low, BIPAP pressures, and high respiratory rates, especially with full-mask 6

7 ventilation. Creating additional leak by removing mask port caps, or by use of an additional, specialized exhalation valve may be required. IX. Documentation: Document PCV by BiPAP on the Mechanical Ventilation Record. X. Complications: 1. Date and time 2. BiPAP ventilator 3. Mode (Spontaneous, CPAP, Timed, Spontaneous/Timed) 4. FIO2 (liter flow) 5. Tidal volume (estimated from machine readout) 6. Respiratory Rate 7. Minute Volume (estimated tidal volume x respiratory rate) 8. PSV (IPAP level) 9. Baseline (EPAP level) 10. High pressure limit 11. Low pressure level 12. Aerodynamic measurements (if performed) 13. Airway temperature 14. Clinical observations recorded in narrative section. 15. Other alarm settings as appropriate. 16. Therapist's initials 17. ABG values will be enter by Cardiopulmonary personnel. When pulse oximeter is in use, record this value at each ventilator check. Complications associated with PSV by BiPAP device include, but are not limited to, the following: COMPLICATIONS: A. Barotrauma- 1) Pneumothorax 2) Pneumomediastinum PRECAUTIONS/ACTIONS: Use least amount of pressure necessary to achieve acceptable clinical results. If pneumothorax is suspected, notify the physician immediately. B. Hypotension Use least amount of pressure necessary. Administration of volume expansion fluids and/or inotropic agents may be of use. C. Worsening of V/A relationships with subsequent hypoxemia and hypercarbia. Use with caution in patients with COPD. If satisfactory results cannot be achieved with this mode of ventilation, discontinue and institute alternate therapy. 7

8 D. Gastric distension/aspiration of gastric contents. E. Facial erosion/erythema Use Nasal CPAP mask if possible. Keep IPAP as low as possible, usually < 22 cm H2O. Insert naso-gastric tube for full face mask ventilation. If aspiration occurs, irrigate and suction vigorously. Support ventilation. Notify physician immediately. Use the least amount of mask pressure needed to maintain seal. Use wound care dressing over the bridge of nose. Use with caution in those patients allergic to mask material and in those patients susceptible to pressure sores (i.e. low perfusion, diabetes).schedule breaks from mask use minutes each two (2) hours or as tolerated F. CO2 rebreathing Use adequate BIPAP machine pressure and flow to achieve adequate minute ventilation an d I:E ratios. Consider use of additional specialized exhalation valve with full mask ventilation. 8

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