Welcome to the Specialized Medical Services Respiratory training webinar series!

Transcription

1 Welcome to the Specialized Medical Services Respiratory training webinar series! SMS is your LTC facility single source for oxygen, medical equipment, respiratory care services and supplies nationwide. This respiratory module is for reference purposes and designed to provide a basic understanding of CPAP / BiPAP Therapy commonly used in Long Term Care. It is still important to consult your local respiratory professional and follow physician orders when applying respiratory treatment. At the completion of each training module, a short post test will be offered, and with successful completion, a training certificate recognizing your participation for your records.

2 CPAP / BiPAP THERAPY Webinar Training Session

3 Training Objectives Understand CPAP / BiPAP therapy What it is used for How to apply the equipment and patient circuit Learn how to troubleshoot

4 What is Sleep Apnea? Sleep Apnea is a disruption in breathing during sleep. Sleep apnea can be central or neurologic in origin, but most commonly it is related to a type of respiratory obstruction, hence the name obstructive sleep apnea (OSA) An episode generally lasts at least 10 seconds Typically occurs more than 5 times in 1 hour Affects more men than women Incidences increase with a person s age

5 What Causes Sleep Apnea? Obstructive Sleep Apnea Soft palate or tongue may obstruct the upper airway Contributing factors include obesity, a large uvula, a neck that is shorter than normal, or enlarged tonsils or adenoids Affects more men than women Incidences increase with a person s age Central Sleep Apnea Breathing repeatedly starts and stops due to lack of respiratory effort Your brain doesn t send proper signals to the muscles that control your breathing May be caused by other medical conditions, such as heart failure or stroke Much less common than OSA, accounting for less than 5% of sleep apneas

6 CPAP or BiPAP Therapy Administered by pressurized system (equipment and patient circuit) that attaches to the patient to relieve airway obstruction, or support ventilation Durable Medical Equipment Electrically driven, low pressure, and flow triggered Patient circuit Reusable or disposable material, variety of headgear configurations (tubing, mask, and headgear) Primarily used for Obstructive Sleep Apnea (OSA) Sleep study (polysomnogram) determines treatment Requires physician prescription for type of therapy (CPAP or BiPAP) pressure setting(s) type of patient circuit and mask (nasal, full face, etc) is oxygen used duration of use (at night, with naps, prn)

7 What is CPAP or BiPAP Therapy? CPAP Continuous Positive Airway Pressure Delivers one constant air pressure at the physician prescribed level throughout the respiratory breathing cycle (inhalation & exhalation). BiPAP Bi-Level Positive Airway Pressure The pressure varies during each breath cycle. During inhalation, the pressure is at its highest point, similar to CPAP. During exhalation, the pressure drops, to a more tolerable level, making it easier to breath. BiPAP is usually ordered for patients requiring a higher pressure for their OSA. BiPAP ST Spontaneous Timed - If the user does not breath on their own, the unit will initiate a breath. A prescribed respiratory rate is set to cycle if the patient does not breath(spontaneous), or at set intervals (timed).

8 Who Sets Up the CPAP/BiPAP unit? The physician prescribed settings on the unit should be set and verified by; The respiratory therapist An authorized service technician A licensed nurse The type of unit and patient circuit should be verified whenever possible; Is this a CPAP or BiPAP unit? Is this an auto adjust or titrating unit? What type of headgear and mask? Nasal mask? Full face mask? Size? The unit should be set-up on the patient by a trained, licensed professional; A respiratory therapist A licensed nurse CONSULT YOUR LOCAL RESPIRATORY PROVIDER WITH SERVICE QUESTIONS ABOUT YOUR UNIT!

9 Who Sets Up the CPAP/BiPAP unit? The unit is programmed to be set in Clinical or Patient mode; The Clinical mode allows the licensed caregiver to adjust settings to prescribed levels The clinical mode is locked, to avoid the patient or caregiver from inadvertently changing the settings The Patient mode is the normal operating mode. This mode allows the patient or caregiver to turn the unit on and off, and will deliver therapy at the pre programmed settings The unit s pre programmed settings do not change when turned off or unplugged. Always maintain a copy of the specific unit s Operating Manual on file as a reference. Your equipment supplier should provide manuals and technical information as needed. You can visit the different manufacturers web-sites to download product information and operating manuals. CONSULT YOUR LOCAL RESPIRATORY PROVIDER WITH SERVICE QUESTIONS ABOUT YOUR UNIT!

10 Equipment Options There are a variety of manufacturers available. Consult your local equipment supplier to standardize the selection process RemStar Basic Synchrony (BiPAP) RemStar Pro Plus w/ Humidifier (CPAP)

11 Other CPAP/BiPAP Features Ramp is a feature that allows for a gradual build-up to the prescribed pressure, helping to improve patient tolerance. Smart or Memory Card is a feature that allows the provider to monitor and download patient compliance. C-Flex is a pressure relief feature that makes breathing against CPAP pressure easier to do by reducing the pressure at the beginning of exhalation. (Respironics) EPR (Expiratory Pressure Relief) EPR is also a pressure relief feature that reduces pressure during exhalation in order to make breathing more comfortable. (Resmed) Auto Adjust or Titrating units is feature that adjusts to your ideal pressure on a breath by breath basis on both CPAP or BiPAP units.

12 Headgear Options (Graphics Courtesy of Respironics) Full Face Mask (Covers Mouth and Nose) Nasal Interface (Covers Nose) Nasal Mask (Covers Nose)

13 Headgear Options (Graphics Courtesy of Puritan Bennett) Nasal Pillows (Fits in Nostrils) Lighter and more comfortable than traditional nasal mask interfaces, the ADAM Interface System is the original CPAP therapy alternative to use Nasal Pillows. The Nasal Pillows, which are available in seven sizes, gently seal at the patient s nares to reduce leaks. The ADAM interface includes Velcro fasteners that permit maximum versatility in fitting and adjustment. Swivel adapter provides stress relief between tubing and shell to avoid dislodging pillows. Tubing routes over patient s head for greater freedom of movement. Four lightweight, adjustable headgear options are available for sleep lab and home use. Medical grade silicone Nasal Pillows in seven sizes fit a wide range of patients.

14 Headgear Options Masks (Graphics Courtesy of Respironics) Profile Lite Comfort Gel Blue Comfort Select Simplicity Nasal Comfort Full 2 Comfort Lite 2

15 Headgear Options (Graphics Courtesy of Respironics) Simple Strap Soft Cap Premium Headgear with EZ Peel Tabs

16 Tubing Options The tubing comes in a variety of lengths to provide flexibility when positioning the patient circuit for application. (usually 6 length is most common) Disposable tubing and headgear are also available for short term use. Reusable Grey Tubing 02 Bleed In Adapter Connected to the tubing and unit to deliver oxygen Reusable Premium Tubing

17 Setting Up the Patient It is important to confirm the prescription and make sure you have the correct equipment, patient circuit, mask, and other accessories (02 bleed in adapter, humidifier, etc.) needed to administer therapy. Your equipment supplier will deliver the equipment and patient circuit to the facility. A respiratory therapist may be scheduled to set up the unit on the patient, or instruction will be provided to the nursing staff when delivered by a service technician. If the patient will need oxygen, be sure to have an oxygen concentrator available. A licensed nurse in the facility should be familiar with the operation, setup of the equipment and patient circuit, and basic troubleshooting. The equipment should be set up on the bedside table at a location close enough so that the circuit and tubing will comfortably reach the patient while in bed. Explain to the patient the prescribed therapy and the treatment plan. Check the settings on the unit to verify they match the prescription, and function test unit to insure proper operation. Connect the mask and headgear to the patient, adjust to a comfortable level, observe for a proper fit that minimizes leaks at the patient interface. Periodically monitor the patient for therapy compliance. CONSULT YOUR LOCAL RESPIRATORY PROVIDER WITH SERVICE QUESTIONS ABOUT YOUR UNIT!

18 Cleaning the Patient Circuit To lengthen the life of your equipment and supplies, it is important to inspect and clean all components regularly. The mask, tubing, and headgear should last approximately 6-12 months, but the actual life can vary by manufacturers material used and cleaning practices. Inspect all components daily and clean as necessary. Daily cleaning is recommended for CPAP/BIAP masks. Other supplies should be cleaned as necessary. Do NOT clean any parts of the system with alcohol, cleaning solutions containing alcohol, bleach, or any strong household type cleaners. Follow these basic steps when cleaning your unit: Wash hands Remove headgear from the mask or nasal pillows. Disconnect the mask or shell (remove pillows from shell), connector, and tubing, With a soft cloth, gently wash the mask or pillows with a solution of warm water and mild, liquid detergent. Rinse thoroughly, if the mask still feels oily, repeat wash. Allow mask or pillows to air dry.

19 Cleaning the Equipment and Maintenance Clean Unit As Necessary. Unplug the unit before cleaning it. Never immerse the unit in water. Using a damp cloth, wipe down the outside of the unit Use a dry cloth to wipe the unit dry, and make sure unit is thoroughly dry before plugging in. Wipe down with a respiratory approved surface disinfectant between patient uses Filter maintenance will depend on the model of the unit. Clean or change the filters at the air intake to keep the internal parts from accumulating dust. All machines have at least one filter, usually of a foam material, and washable. Check the filter routinely for lint accumulation and wash out as needed. Some units have finer filtration with the addition of a disposable paper filter. Replace as needed. Keep the air intake of the machine unblocked. Items like curtains, bedding, and papers can easily block the air intake, reducing airflow. When using a humidifier it is suggested that you do not pick up the machine with the humidifier attached. It is easy to spill water from the humidifier into the machine and cause damage. If you use a humidifier, it is suggested that you empty out the water from the chamber every morning. Do not overfill the humidifier chamber above the refill line.

20 Contraindications When assessing the risks and benefits of using this equipment, the respiratory clinician should always be consulted. Studies have shown that the following pre-existing conditions may contraindicate the use of CPAP or BiPAP therapy. Bullous Lung Disease Pathologically Low Blood Pressure Bypassed Upper Airway Pneumothorax Temporarily contraindicated if the patient exhibits signs of a sinus or ear infection.

21 Invasive CPAP/BiPAP Application (Bypassing Upper Airways) CAUTION Using a non-alarmed CPAP or BiPAP unit for invasive use, that is, connected to a tracheostomy, in a Skilled Nursing Facility, is not approved by the manufacturers. No alarms for power failure or pressure variances Power failure of equipment could result in patient not being able to breathe thru circuit Obstruction of airway from accumulated secretions prevents ventilation Nursing staff not alerted to critical situations The Medical Director and facility assume all liability when this type of clinical application is applied. Facility may be required to sign treatment waiver using this application.

22 Troubleshooting CPAP or BiPAP Problem Possible Cause Correction Mask leaks. Skin irritation. Pressure sores or blisters. Strap adjustment too loose or too tight. Incorrect mask size. Worn-out mask. Dirty mask. Readjust headgear straps. The mask should be as loose as possible while still creating a seal. Consult respiratory therapist for a mask fitting. Nasal pillows or full-face mask may provide a better fit. Inspect mask for stiffness, cracks or breaks. Replace mask if needed. Wash mask daily; wash face nightly. Dry nose and/or throat. Nasal congestion. Epistaxis. Dry air. Try nasal saline spray before bedtime and upon awakening. Add humidification system. Try topical nasal steroid preparation or antihistamines. May have some desensitization over time. Consult physician if symptoms persist. Dry mouth. Sleeping with mouth open. Try a chin strap. If this is not helpful, a full-face mask may be considered. Add heated humidification. Sore, dry, irritated or swollen eyes; conjunctivitis. Mask leaks. Mask too tight. Try reseating the mask on the face. Readjust headgear straps. Inspect mask for stiffness, cracks or breaks. Replace mask if needed. Use an eye patch.

23 Troubleshooting CPAP or BiPAP Problem Possible Cause Correction Rhinorrhea. Dry air. Try saline nasal spray before bedtime. Try topical nasal steroid preparation or intranasal ipratropium bromide before bedtime. Add heated humidification. Allergic rhinitis. Irritants drawn in with room air through machine. Place unit on bedside table to keep dust and/or animal hairs out of machine. Consult respiratory therapist: a fine particulate filter can be added to some units. Add heated humidification. Chest discomfort. Aerophagia. Sinus discomfort. Difficulty exhaling. CPAP unit too noisy. Pressure requirement may be lower at beginning of sleep period. Initial adjustment period. Blocked air intake. Too close to sleeping area. Consult physician if symptoms persist (may require medication) Try pressure ramp at beginning of sleep period. Reduce pressure with bi-level positive airway pressure. Try to reduce pressure requirement by using oral appliance and CPAP (no data available). Check if air filter is clean and not blocked by outside items. Add a length of hose and place unit farther away. Bed partner intolerance. Multiple factors (noise, anxiety). Promote education of the patient and bed partner. Recommend attending a patient support group (i.e., A.W.A.K.E. Network of the American Sleep Apnea Association).

24 Monitoring Patient During Use of CPAP/BiPAP Patient comfort, conscious level Chest wall motion, accessory muscle use Evidence of gastric distension Co-ordination of respiratory effort with CPAP/BiPAP Respiratory Rate SpO2 monitoring, supplementary oxygen should be administered to maintain saturations > 90 % Blood pressure monitoring Duration of use Supply Par Levels Change patient mask, headgear, and tubing on a routine basis

25 Operational Considerations Experience has shown that the best results occur when trial periods of 30 minutes or longer, are attempted on two or three occasions prior to their first overnight trial. Patients who are gradually acclimated to this device in the above mentioned fashion do considerably better than those whose initial exposure/trial is initiated at bedtime. Patients should refrain from eating 1-2 hours prior to the application of the BiPAP/CPAP system. Supplemental humidification, can be provided by a humidifier. Experience has shown that with adult patients, forgoing the addition of a humidifier for 2-3 days in most instances negates the need for such a device. The patient's mucociliary blanket appears to adapt to the new conditions.

26 Operational Considerations Oximetry should be performed prior to the initiation of this therapy as well as when the BiPAP/CPAP system is in place. The oximetry will not only aid in the titration of the oxygen but will serve as tool to monitor the effectiveness of this therapy. Although no reports of gastric distension or aspiration have been reported, the most common complication has been abrasion of the bridge of the nose. Application of wound-care dressing appears to eliminate this problem.

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28 Steps to Follow Identify patient need Verify MD prescription Equipment type, patient circuit, settings Verify set up / information with supplier Monitor treatment for benefit & continued need Follow best practice and safety guidelines

29 CPAP or BiPAP Therapy Sample Orders What does a CPAP or Auto CPAP prescription need to say? Contains a description of the machine: CPAP, Auto CPAP Contains your physician's prescription and signature. Contains the patient's full name Contains your pressure (CPAP ) Example: CPAP 8 CM/H20 Contains your expiratory pressure (EPAP) Example: EPAP 5 CM/H20 Contains your inspiratory pressure range Auto CPAP Contains your pressure range Example: CPAP 6-10 CM/H20

30 CPAP or BiPAP Therapy Sample Orders What does a BiPAP, Auto BiPAP, or BiPAP ST prescription need to say? Contains a description of the machine: BiPAP, Bi Level, Auto BiPAP, BiPAP ST Contains your physician's prescription and signature. Contains the patient's full name Contains your inspiratory pressure (IPAP ) Example: IPAP 15 CM/H20 Contains your expiratory pressure (EPAP) Auto BiPAP Example: EPAP 5 CM/H20 Contains your inspiratory pressure range Contains your inspiratory pressure range Example: IPAP pressure range 8-15 CM/H20 Contains your expiratory pressure (EPAP) BiPAP ST Example: EPAP pressure 6 CM/H20 Contain a backup rate or Breath Per Minute BPM setting Set on Spontaneous or Timed

31 CPAP or BiPAP Therapy Sample Orders What does a mask prescription need to say? Contains one of the following descriptions or phrases: CPAP Mask, "CPAP Supplies, BiPAP Circuit, Type and size of mask (Large Full, Medium Nasal), Type of Headgear Contains physician's contact information Contains physician's signature Contains the patient's full name What does a humidifier prescription need to say? Contains one of the following descriptions or phrases: "CPAP Humidifier", "Humidifier", "HH", Contains your physician's contact information Contains your physician's signature Contains the patient's full name

32 Session Review Understand CPAP / BiPAP therapy What it is used for How to apply the equipment and patient circuit As a caregiver, it is important to understand what therapy to use in different clinical circumstances, and how to monitor the effectiveness of the therapy prescribed. Consult your Equipment Supplier or local Respiratory Therapist with application questions.

33 Other CPAP / BiPAP Therapy Resources AARC Clinical / Technical References Manufacturers product material CareFusion Covidien Fisher Paykel Phillips Respironics ResMed Corp On Line Reference

34 Thank You! Take our post-session quiz and print your certificate of completion