LUNG EXPANSION
IS, PAP, PEP, IPPB, IPV,
PEEP/CPAP and BIPAP
Atelectasis
• Causes
Surgery
• Upper abdominal surgery risk greater than lower
abdominal
• Thoracic surgery
Atelectasis
• Causes
– Obesity
– Neuromuscular disorders
– Sedation
Atelectasis
• Causes
– Spinal cord injuries
– Non-ambulation/bed rest
– Ineffective cough
Types of Atelectasis
• Reabsorption atelectasis
– Caused by the blockage of airways by mucus
plugs; associated with lobar or segmental
atelectasis
Types of Atelectasis
• Passive atelectasis
– Caused by persistent use of small tidal
volumes, use of sedatives and bed rest,
when deep breathing is painful, and
weakened diaphragm
Clinical Signs of Atelectasis
• Increase in respiratory rate
• Fine, late inspiratory crackles during
auscultation
• Diminished breath sounds
Clinical Signs of Atelectasis
• Tachycardia, if there is significant
hypoxemia associated with the
atelectasis
• Fever
Clinical Signs of Atelectasis
• X-Ray
– Increased opacity
– Air bronchograms
Clinical Signs of Atelectasis
• X-Ray
– Elevation of diaphragm
– Shift of trachea, heart, or mediastinum
toward the affected side
Lung Expansion Therapy
• Increases transpulmonary pressure (PL)
PL = Palv – Ppl
– Decrease in Ppl by a sustained inspiratory phase;
more physiological
– Increase in Palv by use of positive pressure
Lung Expansion Therapy
• Goal is to choose most effective means in
most efficient manner
Methods of Administration
• Incentive spirometry
– Also known as sustained maximal inspiration (SMI)
– Slow, deep inspiration from FRC to TLC followed by
a 5 to 10 second hold
Methods of Administration
• Incentive spirometry
– Functionally equivalent to performing
inspiratory capacity with breath hold
Incentive Spirometry
• Indications
– Presence of conditions predisposing to
development of atelectasis
– Presence of atelectasis
Incentive Spirometry
• Indications
– Presence of restrictive lung defect
associated with quadriplegia and/or
dysfunctional diaphragm
Incentive Spirometry
• Contraindications
– Patient unable to understand
instructions well enough to ensure
effective use of the spirometer
Incentive Spirometry
• Contraindications
– Patient unwilling to cooperate or cannot
demonstrate ability to use the device
– Patient unable to deep breathe effectively
(VC < 10 ml/kg)
Incentive Spirometry
• Hazards and complications
– Hyperventilation leading to respiratory
alkalosis
– Ineffectiveness unless supervised or
performed as ordered
Incentive Spirometry
• Hazards and complications
– Exacerbation of bronchospasm
– Barotrauma
– Fatigue
Incentive Spirometry
• Hazards and complications
– Discomfort secondary to inadequate pain control
– Hypoxemia secondary to removal of oxygen to
perform the therapy
Monitoring IS Treatment
• Observation of patient performance and
use
– Frequency of sessions
– Number of breaths per session
– Volume/flows achieved
Monitoring IS Treatment
• Observation of patient performance and
use
– Breath hold sustained
– Vital signs, including breath sounds
– Motivation of patient
Monitoring IS Treatment
• Observation of patient performance
and use
– Device available to patient
– Reassessment of daily goals
– Additional instruction, as needed
Monitoring IS Treatment
• Direct supervision of each procedure not
required once patient has mastered
technique
Assessment of Outcome
• Absence or improvement of atelectasis
• Decrease/normalization of respiratory rate
• Resolution of fever
• Absence of crackles or increase in breath
sounds
Assessment of Outcome
• Normal X-Ray
• Improved PaO2
• Increase in VC and peak expiratory flows
Incentive Spirometry
Volumetric IS
Flow Oriented IS
PEP and PAP
PAP
• Positive airway pressure (PAP) adjuncts are used to
mobilize secretions and treat atelectasis and include
– continuous positive airway pressure (CPAP)
– positive expiratory pressure (PEP)
– expiratory positive airway pressure (EPAP).
• Cough or other airway clearance techniques are
essential components of PAP therapy when the
therapy is intended to mobilize secretions
Terminology
• PAP: positive airway pressure. This is a universal term, applied
to any positive pressure application to the lung. No single
device is called PAP, instead it encompasses all devices that
deliver positive pressure
• PEP: Positive expiratory pressure. Typically given as a
expiratory retard, or expiratory impendence/resistor. Devices
include the flutter, EZPAP, therapep or simply performing
pursed lip breathing. PEP also includes PEEP, however, when
we say “PEP” we are referring to a device such as those listed
above.
Terminology
• PEEP: Again, PEEP is PEP; however, we refer to PEEP
as a setting on mechanical ventilation. Typically it is
referring to extrinsic PEEP, or PEEP that is applied to
the airway through mechanical ventilation.
• EPAP: EPAP, PEP and PEEP are all expiratory pressures
a patient must exhale against. This term is however
used while a patient is on BiPAP ventilation/ also
known as Bilevel ventilation or non-invasive positive
pressure ventilation.
Devices
MetaNeb/Cough Assist
PAP: CPAP
• The patient breathes from a pressurized circuit
against a threshold resistor (water-column,
weighted, or spring loaded) that maintains
consistent preset airway pressures from 5 to 20 cm
H2O during both inspiration and expiration
– (By strict definition, CPAP is any level of aboveatmospheric pressure.)
• CPAP requires a gas flow to the airway during
inspiration that is sufficient to maintain the desired
positive airway pressure.
PAP: CPAP
• Types of threshold resistors: all of these valves
operate on the principle that the level of PAP
generated within the circuit depends on the
amount of resistance that must be overcome to
allow gas to exit the exhalation valve.
• They provide predictable, quantifiable, and constant
force during expiration that is independent of the
flow achieved by the patient during exhalation
PAP: CPAP
• Underwater seal resistor:
– expiratory port of the circuit is submerged under a
column of water, the level of CPAP is determined
by the height of the column
• Weighted-ball resistor:
– consists of a steel ball placed over a calibrated
orifice, which is attached directly above the
expiratory port of the circuit
PAP: CPAP
• Spring-loaded:
– rely on a spring to hold a disc or diaphragm down over the
expiratory port of the circuit.
• Magnetic valve resistors
– contain a bar magnet that attracts a ferromagnetic disc
seated on the expiratory port of the circuit the amount of
pressure required to separate the disc from the magnets is
determined be the distance between them.
PAP: PEP
• The patient exhales against a fixed-orifice
resistor, generating pressures during expiration
that usually range from 10 to 20 cm H2O
• PEP does not require a pressurized external gas
source.
• The amount of PEP varies with the size of the
orifice and the level of expiratory flow produced
by the patient. The smaller the orifice the
greater the pressure.
PAP: PEP
• Thus the patient must be encourage to generated a
flow high enough to maintain expiratory pressure at
10-20 mm H2O
• Ideal I:E of 1:3 or 1:4
• The patient should perform 10-20 breaths through
the device and then perform 2-3 huff breath coughs
• This should be repeated 5-10 times during a 15-20
minute session
PAP: EPAP
• The patient exhales against a threshold resistor,
generating preset pressures of 10 to 20 cm H2O
(similar to CPAP expiration)
• EPAP does not require a pressurized external gas
source.
• EPAP utilizing threshold resistors does not
produce the same mechanical or physiologic
effects that PEP does when a fixed orifice
resistor is used.
• Further study is necessary to determine how
these differences affect clinical outcome.
INTERMITTENT POSITIVE PRESSURE
BREATHING
IPPB
• Intermittent Positive Pressure Breathing (IPPB)
is a short-term breathing treatment where
increased breathing pressures are delivered
via ventilator to help treat atelectasis, clear
secretions or deliver aerosolized medications
• IPPB can include pressure- and time-limited,
as well as pressure, time, and flow-cycled
ventilation.
• IPPB may be delivered to artificial airways and
non-intubated patients.
IPPB
• INDICATIONS:
The need to improve lung expansion
The presence of clinically significant
pulmonary atelectasis when other forms of
therapy have been unsuccessful (incentive
spirometry, chest physiotherapy, deep
breathing exercises, positive airway pressure)
or the patient cannot cooperate
IPPB
• Inability to clear secretions adequately
because of pathology that severely limits the
ability to ventilate or cough effectively and
failure to respond to other modes of
treatment
• The need for short-term ventilatory support
for patients who are hypoventilating as an
alternative to tracheal intubation and
continuous mechanical ventilation
IPPB
• The need to deliver aerosol medication.
• IPPB may be used to deliver aerosol medications to
patients with fatigue as a result of ventilatory muscle
weakness (eg, failure to wean from mechanical
ventilation, neuromuscular disease, kyphoscoliosis,
spinal injury) or chronic conditions in which
intermittent ventilatory support is indicated (eg,
ventilatory support for home care patients and the
more recent use of nasal IPPV for respiratory insuff
iciency)
IPPB
• Assessment of need:
– Presence of significant atelectasis
– Reduced pulmonary function, reduced VC, VT
– Neuromuscular disorders
– Prevention of atelectasis
Assessment of Outcome:
– Minimum VT of at least 1/3 of predicted IC
– Increase in FEV1
– More effective cough, CXR improved, BS improved
IPPB
• CONTRAINDICATIONS:
There are several clinical situations in which
IPPB should not be used. With the exception
of untreated tension pneumothorax, most of
these contraindications are relative:
– Increased ICP >15 mmHg
– Hemodynamically unstable
– Recent Facial, oral or skull surgery
– Tracheoesphogeal fistula
IPPB
– Recent Espohageal surgery
– Active hemoptysis
– Nausea
– Air swallowing
– Active TB
– Blebs
– Singulation (hiccups)
IPPB
• Hazards/complications
– Increased RAW and WOB
– Barotrauma/pneumothorax
– Nosocomial infection
– Hypocarbia
– Hemoptysis
– Hyperoxia when O2 used as gas source
– Gastric distension
– Impaction of secretions
IPPB
– Impendance of venous return
– Air trapping
Limitations of Device
– Effects are short lived, lasting an hour
– Delivery of medication is ineffective due to low
delivering flow through nebulizer
– Patient dependent
– IPPB equipment is labor intensive
– Limited portability
IPPB
• IPPB is pneumatically powered
• Patient triggered and pressure cycled
• You set: Pressure limit, flow, sensitivity
IPPB
• Given through a mouth piece or mask
• Varying types, BIRD Mark series, PB
IPPB Setup
Flow rate
adjustment.
Sensitivity
adjustment
Pressure
adjustment
Pressure manometer.
Negative should not be
more than -2, if it is
adjust your sensitivity
Air mix,
either
100% if
pushed in
or 80%
pulled out
IPPB
• How the machine works:
• In IPPB, we set a driving pressure [PIP] on the
machine, and when the patient triggers the
machine by decreasing the pressure in the
line, gas starts to move down the tube into
the mouth and airways.
• When the preset PIP is reached, the gas flow
shuts down immediately. The inspiratory
phase has cycled off.
IPPB: Pressure
• Pressure set on the IPPB will determine the
pressure limit
• Pressure is directly related to volume,
increasing the pressure limit will increase the
volume in the lung
• Measure VT with
• Venti-comp bag
IPPB Pressure
• Pressure is typically started low, around 10-15
cmH2O and increased to achieve desired VT.
Remember, IPPB is hyperinflation therapy, the
goal is to exceed normal tidal volume ranges.
• Once the machine is triggered on by the
patient and pressure is reached (seen on
manometer) the machine cycles off
• Too much pressure can cause barotrauma
IPPB Flow
• The flow setting on the IPPB dictates how fast
the pressure limit is reached
• High flow = low inspiratory time
• Low flow = high inspiratory time
• Start low around 5-10 L and increase
depending on the desired inspiratory time
• Normal times should be around 1-1.5 seconds
for inspiration
IPPB Flow
• To decrease the inspiratory time we need to increase
the flow rate
• To increase the inspiratory time, we need to
decrease the flow rate
• If we increase the PIP to increase the VT, sometimes the
inspiratory time is too long and we have to increase the flow
rate.
• Remember that really fast flow rates will only cause increased
RAW, so keep the inspiratory time between 1-1.5 seconds for
adults.
• Remember that the air mix mode involves air entrainment so
the flow rate will be changed by changing the Fi02
IPPB Sensitivity
• The sensitivity on the IPPB machine is
manipulated by the dial on the left hand side
of the machine. Increasing the “Inspiratory
Effort” dial will make the machine less
sensitive to the patients inspiratory trigger.
This increases the magnetic pull inside the sub
atmospheric side of the ,IPPB bird machine
making it more difficult for the patient to
trigger the machine on, increasing WOB
IPPB Sensitivity
• Decreasing the “patient effort” dial will make
the machine more sensitive to the patients
inspiration.
• This may cause “auto-triggering” if it is set too
low.
• Decreasing this dial creates less magnetic pull
on the diaphragm in the middle of the
machine
IPPB FIO2
• If you do not wish to deliver high FIO2 to the
patient during the IPPB procedure, attach the
machine to a air outlet, otherwise the only
two FIO2 available are 100% or 80% with air
dilution
• NOTE: on the IPPB machine there is a APNEAexpiratory time setting, do not turn this on
unless you want a back up rate.
Breathing while on IPPB
• Remember, this is not ventilation. IPPB is a
sustained maximal inspiration just like IS, so
we do not need to breathe much faster than
6-8 bpm. The patient may breathe faster, but
he can do so off the IPPB.
• Rapid RR on the IPPB will increase chances of
impeding venous return to the heart, reducing
the amount of blood in the heart which would
cause the patient to become tachycardiac in
order the keep the same cardiac output.
Breathing while on IPPB
• If the patient becomes light headed, dizzy or
feels tingling in their fingers during the
procedure- STOP and allow patient to rest, this
is caused by the quick elimination of CO2
• Rapid RR will encourage air trapping,
particularly in persons with increased RAW
and wheezing—we need plenty of time to
exhalation
Breathing while on IPPB
• We need to allow for a 3-5 second inspiratory
hold.
• Remember this is a SMI, that includes a slow
deep breath and inspiratory hold to get the
gas and the medications deep into the
periphery of the lung. The patient can take his
mouth off the IPPB mouthpiece to do this
breath hold—unless we need to measure the
VT.
IPPB Troubleshooting
• If you checked your PIP by watching the monometer while you occlude the
patient connector, you will find most problems before attaching the
machine to the patient. The pressure should go right to the PIP and stop
immediately. The machine should not start just because you jiggle the
tube.
• Is the machine set for appropriate Fi02?
• Is the sensitivity set for -2?
• Check the PIP by monometer—not just the number on the dial
• Is the circuit on nice and tight-do a tactile exam, not just looking at it.
• If the SVN is set separately, is it set correctly
?
IPPB Troubleshooting
•
•
•
•
Breath will not come on
1. attach the high pressure line to the gas
2. turn on the flow rate
3. check the sensitivity; set the machine to
trigger by itself [auto-cycling] then turn back a
bit.
• 4. does the patient have a tight seal? Mouth
closed? Lips tight, nose closed or nose clips?
IPPB Troubleshooting
• Breath starts too easily
• 1. sensitivity is set too low. Auto-cycling is when the
machine triggers itself just by jiggling the tube.
• Breath will not end
• 1. check the flow rate; too slow
• 2. does the patient have a tight seal? Mouth closed?
Lips tight, nose closed or nose clips? LEAKS
• 3. check the mushroom valve, the nebulizer line, the
nebulizer cup and the mainline for leaks.
IPPB Troubleshooting
• Inhalation goes on past 1-1.5 seconds
• 1. flow rate is too slow for this patient
• 2. check for small leaks that prevent the pressure from rising.
Look at the pressure on the monometer, there should be a
steady rise in pressure
• 3. if the pressure is wavering just lower than the PIP, the
patient is ‘leading the machine.’ Ask him to relax & let the
machine do the work.
• He is inhaling too fast—also increase the flow rate per his
comfort level
• 4. if you moved from air mix to 100% Fi02, you lost the
entrainment so the flow rate needs to be increased again
INTRAPULMONARY
PERCUSSONATOR
IPV
• Intrapulmonary percussive ventilation (IPV) is a therapeutic
modality designed to clear and maintain pulmonary airways.
IPV is used to mobilize and clear retained secretions, assist in
the resolution of atelectasis, and to deliver aerosolized
medications. Oscillatory pulsations are delivery by the
"Percussionator" which generates high frequency bursts of
gas at rates of 100 to 300 cycles per minute (2 – 5 Hz). The
mini bursts of air are delivered to the patient's airways at
pressures of 10 – 20 cm H20, however this range may be
adjusted to match the compliance and resistance of the lung
and chest wall.
IPV
• IPV was depicted as delivering “high flow mini-bursts
of air along with bronchodilator to the lungs at a rate
of 300–400 times per minute.”
• operates at 1.7 Hz to 5 Hz and generates esophageal
pressure and airflow oscillations
• Treatments last about 15–20 min
• This device is designed to be used in conjunction
with conventional mechanical ventilation, if desired,
or as a stand-alone treatment device. It can be used
with a mouthpiece or mask, and it can also deliver
aerosolized medication.
IPV
• http://www.youtube.com/watch?v=ARJLALFf2
e0
• Pneumatically powered
• Nebulizer cup, uses a phasitron to create
oscillations, bacterial filter, circuit- colored
coded- connect lines to device
• Set Drive pressure (based on patients
compliance)
• Set percussion level
PEEP
• Positive end-expiratory pressure (PEEP) is the
pressure in the lungs (alveolar pressure) above
atmospheric pressure that exists at the end of
expiration. The two types of PEEP are extrinsic
PEEP (PEEP applied by a ventilator) and
intrinsic PEEP (PEEP caused by a non-complete
exhalation).
PEEP
• There are three purposes to using PEEP:
• 1) To prevent derecruitment, by returning the
functional residual volume to the physiologic range.
2) To protect the lungs against injury during phasic
opening an closing of atelectatic units.
• 3) To assist cardiac performance, during heart
failure, by increasing mean intrathoracic pressure.
PEEP
• Applied (Extrinsic) PEEP — Applied PEEP can be given
through invasive or non-invasive ventilation.
• Works by increasing alveolar pressure to increase
FRC, Mean Airway pressure and ultimatley improve
compliance and improve oxygenation
• PEEP is given in the range of about 3-5 and used to
mitigate end-expiratory alveolar collapse. A higher
level of applied PEEP (>5 cmH2O) is sometimes used
to improve hypoxemia or reduce ventilatorassociated lung injury in patients with acute lung
injury, acute respiratory distress syndrome, or other
types of hypoxemic respiratory failure
A: Collapsed alveoli on exhalation without PEEP
B: Inflated alveoli on exhalation with PEEP
C: Inflated alveoli on inspiration with PEEP
Auto-Peep (Intrinsic Peep)
• Auto-PEEP is gas trapped in alveoli at end
expiration, due to inadequate time for
expiration, bronchoconstriction or mucus
plugging. It increases the work of breathing.
• Auto-PEEP is caused by gas trapped in alveoli
at end expiration. This gas is not in equilibrium
with the atmosphere and it exerts a positive
pressure, increasing the work of breathing,
Auto-Peep (Intrinsic Peep)
• The problem with gas trapping or “auto PEEP” is that gas trapped in the
airways exerts a positive pressure, and normal gas transit cannot be
reestablished until there is a pressure gradient from the mouth to the
alveoli. Thus the patient must generate a much higher negative inspiratory
pressure to open up dynamically compressed airways (to make the
pressure within negative with respect to atmospheric pressure).
• If auto-PEEP occurs during mechanical ventilation, the amount of time
given over to expiration needs to be lengthened: either by reducing the
respiratory rate or the inspiratory time, or both.
CPAP
• CPAP is the application of continuous positive
airway pressure, patient is breathing
spontaneously. Pressure is at one level
• CPAP is a mode, and also a setting
• Synonymous with PEEP, and EPAP
• Given for a variety reasons, including:
– Refractory hypoxemia
– OSA
– RDS…
CPAP
• CPAP can be applied non-invasively, through a
BiPAP machine, CPAP machine, or SiPAP
machine or it can be given invasively through
a continuous mechanical ventilator
• CPAP is otherwise known as PEEP, can be given
to all age groups
NASAL CPAP
Home vs. Hospital
NPPV
• Application of positive pressure without
airway intubation for the purpose of
augmenting alveolar ventilation
• Patient’s using NPPV are typically awake/alert
and breathing spontaneously
Goals of NPPV
• Acute Care
– Avoid intubation
– Improve mortality
– Relieve symptoms
– Enhance gas exchange
– Improve ventilator-patient synchrony
– Maximize patient comfort
– Decrease incidence of ventilator-acquired pneumonia (VAP)
Goals of NPPV
• Chronic Care
– Relieve or improve symptoms
– Enhance quality of life
– Avoid hospitalization
– Increase survival
– Improve mobility
Indications for NPPV
• Disease states
– Asthma
• Used in treatment of acute attack to avoid intubation, HHN can be given
inline
• Many tend to be claustrophobic and don’t tolerate procedure
– Acute exacerbation of COPD
• Studies indicate that NPPV should be first-line intervention in treatment
• Only beneficial in acute exacerbation/HHN treatment can be given inline
– Acute cardiogenic pulmonary edema
• Administered as first-line treatment, NO HHN treatment indicated
• Not recommended for patients with myocardial infarction, arrhythmias,
hemodynamic instability, or depressed mental status
Indications for NPPV
• Other indications
– Neurologic/neuromuscular disease
• Should always be considered as a first-Line treatment
• Works well when applied to patients with
progressively deteriorating disease
• Will use NPPV until the patient requires invasive PPV
– Weaning from ventilatory support
• May be indicated for patients who have failed at
weaning attempts but for whom clinical signs
indicate they should be weaned
• May be used with patients failing extubation
Indications for NPPV
• Other indications
– Immunosuppressed patients/patients awaiting lung transplant
• Avoidance of intubation – leads to nosocomial pneumonia
• Should always be considered as a first-Line treatment
– Acute lung injury
• Should be applied with caution to ALI patients
• If no response within a few hours, patient should be intubated
– DNR patients (controversial)
• Used to prolong life until family members arrive
• Used to transport patient home to die
• Provide comfort during last hours of life
Indications for NPPV
• Chronic care settings
– Relief of nocturnal hypoventilation in COPD patients
– Nocturnal use for restrictive thoracic diseases
• Rest respiratory muscles
• Lower PaCO2 to establish new baseline value
• Improve lung compliance, lung volume, and reduce dead space
– Treat nocturnal hypoventilation
• Obesity hypoventilation
• Obstructive sleep apnea
• Central sleep apnea
NPPV for OSA
Patients with OSA often use CPAP via face, nasal or nasal pillow
masks. Often poorly tolerated.
NPPV for OSA
• Obstructive sleep apnea (OSA) is the most common type of
sleep apnea and is caused by obstruction of the upper airway.
It is characterized by repetitive pauses in breathing during
sleep, despite the effort to breathe, and is usually associated
with a reduction in blood oxygen saturation. These pauses in
breathing, called apneas (literally, "without breath"), typically
last 20 to 40 seconds.
• The individual with OSA is rarely aware of having difficulty
breathing, even upon awakening. It is recognized as a problem
by others witnessing the individual during episodes or is
suspected because of its effects on the body (sequelae). OSA
is commonly accompanied with snoring.
• Leads to cardiac problems, brain problems, HTN…
Selection Criteria for NPPV in
Acute Respiratory Failure
• Use of accessory muscles
• Paradoxical breathing
• Respiratory rate > 25 breaths/min
• Dyspnea (moderate to severe or increased over
normal levels)
• PaCO2 > 45 mmHg with pH < 7.35
• PaO2/FIO2 ratio < 200
BiPAP
• Two levels of non-invasive positive pressure.
• BiPAP is a trademarked name from Respironics
• IPAP: Inspiratory positive airway pressure, a
pressure limit, increases in IPAP = increases in
VT
• EPAP: Expiratory positive airway pressure,
PEEP, applied on expiration to increase FRC
• Set IPAP and EPAP at least 5 apart to create a
pressure gradient, this difference is called
pressure support
Bipap
• The BiPAP machine has two basic modes:
– S/T (Spontaneous timed): You set a IPAP, EPAP,
Rate, inspiratory time and FIO2. The rate only
applies when the patient falls below the minimum
back up rate, once he or she does the machine is
termed time cycled. Otherwise all breaths are
spontaneously triggered. Set alarms
– CPAP: Set a PEEP/EPAP level, along with FIO2, no
back up rate set. Watch for apnea, set apnea
alarm
Bipap
• Typical settings for Bipap:
– IPAP 10-15 cmH2O (increase or decrease based on PaCO2)
– EPAP 5-10 cmH2O (increase/decrease based on PaO2)
– Rate 6-10 (rate set low, patient should be breathing
spontaneously)
– FIO2 21-100% (based on SpO2, PaO2…)
– I-time 1.0 second (usually a non issue since rate is low)
– Rise time 0.4 seconds (only applies to timed breath)
– Once BiPAP is applied, assess comfort, monitor Vte, RR,
HR, SpO2, BP, cardiac rhythm, Ve…
– Get a ABG about 1-2 hours after initiation
– Leaks are the number one cause of alarm
BiPAP
• Bipap is typically setup quickly with the mask
being the most cumbersome aspect of setup
• BiPAP should be used as a temporary means
of augmenting/ assisting in a patients
respiratory distress. Prolonged use typically
suggests the patient may need intubation
• Commonly used in the ER for CHF/pulmonary
edema, but also for a wide range of other
reasons
Bipap
• The most important factors in applying BiPAP
are:
– Is the patient a proper candidate for BiPAP or do
they need to be intubated
– Note contraindications for device
– Is the mask appropriate for the patient (correct
size and fit)
– Proper settings
Exclusion Criteria for NPPV in
Acute Respiratory Failure
• Apnea (NPPV/BIPAP only for spontaneously breathing pts)
• Hemodynamic instability
• Uncooperative patient behavior (may need sedation)
• Facial burns or other trauma
• Copious secretions (Devices can dry secretions)
• High risk of aspiration
• Anatomic abnormalities that interfere with gas delivery
Exclusion Criteria in the
Chronic Care Setting
• Unsupportive family
• Lack of financial resources
• Uncooperative patient behavior
• Copious secretions
• High risk of aspiration
• Anatomic abnormalities that interfere with gas delivery
• Ventilatory support required most waking hours
Administration of NPPV –
Patient Interfaces
• Nasal mask
– Triangular in shape; made to fit
around the nose
– Most common interface
– Fitting of mask dependent upon
manufacturer’s specifications
– Leakage through the mouth can be a
significant problem, may need chin
strap
Administration of NPPV –
Patient Interfaces
• Full face masks
– Surrounds nose and mouth, resting below lower
lip
– Seal easier to maintain because both mouth and
nose covered
– Associated with increased dead space, risk of
aspiration, and claustrophobia
– Asphyxiation can occur in Ventilator failure so
alarms must be functional
Administration of NPPV –
Patient Interfaces
• Nasal pillows
– Consists of two small cushions that fit
under the nose
– Has limited pressure range of use – 3 to
20 cmH2O
– More comfortable than facial masks,
but gas leakage may
be a problem. Gas leaks out of the
mouth, may need chin strap
Administration of NPPV –
Patient Interfaces
• Total face mask
– Surrounds entire face
– One size available for quick
application in emergencies
– Does have increased dead space, but
decreases claustrophobic feeling
because it does not obscure vision
– Alternate masks to reduce
pressure sores on face
Administration of NPPV –
Humidification
• Heated humidification has been noted to
decrease nasal resistance and congestion
• Cold passover humidification does not
significantly relieve nasal resistance
• Heated humidification increases patient
compliance with the procedure
Administration of NPPV –
Initiation
• Successful application requires that the
patient be part of the process. They must
understand what is to be done and be fully
cooperative in the process.
Administration of NPPV –
Initiation
• Place patient at an angle ≥ 30⁰
• Determine correct size and type of patient interface (very important, if
patient is uncomfortable they are non-compliant)
• Attach patient interface to circuit
• Select initial settings
– PEEP: 0 – 4 cmH2O
– Ventilating pressure: < 5 cmH2O (typically 10-15)
– Expected VT: 200 – 500 mL
• Once you input your settings and alarms connect to patient
Administration of NPPV –
Initiation
• Select initial settings
– FIO2: maintain SpO2 > 90%
– Rate: determined by patient, again set low
Administration of NPPV –
Initiation
• Hold the mask on the patient’s face or have
the patient hold the mask on the face
• When patient is comfortable with mask, use
straps to hold in place
• Do not overly tighten or let too loose
Administration of NPPV –
Initiation
• Adjust FIO2 as necessary to maintain SpO2 >
90%
• Adjust mask as necessary to correct any air
leaks, do not put tape on mask to prevent
leaks. Ensure exhalation ports are open
Administration of NPPV –
Initiation
• As patient becomes comfortable, adjust
inspiratory positive airway pressure (IPAP)
until VT is between 4 and 6 mLs/kg or until
signs of respiratory distress improve
Administration of NPPV –
Initiation
• Increase expiratory positive airway pressure
(EPAP or PEEP) to reduce dyssynchrony from
air trapping or to improve oxygenation
Administration of NPPV –
Assessment
• Assessment after initial two hours indicating
successful administration
– Decrease in PaCO2
– Increase in pH
– Increase in PaO2
– Decreased WOB
Administration of NPPV –
Assessment
• Assessment after initial two hours indicating
successful administration
– Decrease in respiratory rate
– Normalization of heart rate and respiratory rate
– Normalization of ventilatory pattern
Administration of NPPV –
Assessment
• Failure to observe improvement requires
reassessment to determine need for intubation
• If patient shows some signs of improvement,
continue to evaluate to determine success or failure
of procedure and initiate appropriate action
• NPPV should be used as a short term application, or
used on a nightly or intermittent basis
Administration of NPPV –
Assessment
• Be cautious to avoid prolongation of the
procedure; allowing patient to continue too
long without significant improvement can
create difficulties for intubation or
stabilization later
Side Effects
Side Effect
Mask related
Discomfort
Facial skin erythema
Claustrophobia
Nasal bridge ulceration
Acneiform rash
Air pressure or flow related
Nasal congestion
Sinus or ear pain
Nasal or oral dryness
Eye irritation
Gastric insufflations
Possible Remedy
Check fit, adjust strap, change to new type of
mask
Loosen straps, apply artificial skin
Use a smaller mask, change type of mask,
give sedative
Loosen straps, apply artificial skin, change
mask type
Administer topical steroids or antibiotics
Administer nasal steroids, decongestant, or
antihistamines
Reduce pressure if pain is intolerable
Apply nasal saline solution, add humidifier,
decrease leak
Check mask fit, readjust straps
Reassure the patient, give simethicone,
reduce pressure to relieve excessive pain
Side Effects
Side Effect
Air leaks
Major complications
Aspiration pneumonia
Hypotension
Pneumothorax
Possible Remedy
Encourage mouth closure, try chin straps, try
oronasal mask if using nasal mask, reduce
pressure slightly
Select patients carefully
Reduce IPAP
Stop ventilation if possible, reduce airway
pressure; insert chest tube if indicated
Side Effects
Slow skin breakdown by applying Mepilex or DuoDerm tape
to patient’s face, typically the bridge of the nose and
forehead and sides of face
Contraindications
• Absolute
– Untreated pneumothorax
– Patient without a paten airway
– Apnea
– Inability to fit interface due to deformity
Contraindications
• Relative
– Unstable hemodynamic state
– Facial trauma