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
HW assignment
• Part 1. Assess the use and application of IPPB and IPV as a
means for hyperinflation and bronchial hygiene therapy. Is
there evidence supporting there effective use? (2 pages)
• Part 2. Explain why or why not the use of BiPAP in DNR
patients is justified. I want your opinion on the ethical
implications as well as the functionality of the Bipap as a
ventilation assistant(2 pages)
• Use peer reviewed literature to write a minimum of two pages
on each topic. You may email me your articles or attach them
with your paper. Use correct referencing
• DUE OCTOBER 8th
• Michaines@hotmail.com