Non-Invasive Ventilation in the Non-ICU Setting, by Julie Gemignani.
Hi, I'm Julie Gemignani.
I work in the respiratory care department here at Children's Hospital.
Today, we're going to discuss non-invasive ventilation in the non-ICU setting.
We will review the types of non-invasive ventilation.
These include BiPAP and CPAP.
We will also include the equipment used during non-invasive ventilation and how it should
be operated.
We will review the masks that are used in non-invasive ventilation, and, finally, we
will review how to assess a patient who is on non-invasive ventilation.
Types of Mechanical Ventilation.
So what is CPAP?
CPAP is continuous positive airway pressure.
It is one constant level of positive pressure applied throughout the inspiratory and expiratory
phase of a spontaneously breathing patient.
The indication for CPAP is chronic respiratory insufficiency.
It is often associated with the following conditions:
Hypoxemia, for example, cystic fibrosis patients or treatment for obstructive sleep apnea or
OSA.
So what is BiPAP?
BiPAP is bilevel positive airway pressure.
It assists ventilation delivered non-invasively by means of a nasal or facial mask or other
types of nasal interfaces.
With BiPAP, there are two levels of positive airway pressure.
One is for the inspiratory phase and one is during the expiratory phase.
The indication for BiPAP is chronic respiratory insufficiency.
It is often associated with the following conditions: chronic lung disease, hypoventilation
syndromes, neuromuscular disorders, thoracic cage abnormalities, and obstructive sleep
apnea.
So BiPAP verse CPAP.
CPAP is the preferred mode for improving oxygenation.
The major indication for CPAP in the non-acute setting is obstructive sleep apnea.
With BiPAP, the difference in pressures help to eliminate CO2 from the body, therefore,
improving ventilation.
Some complications for non-invasive ventilation are dyssynchrony, or the inability to reach
set pressures due to a large leak around the mask, gastric distension, aspiration of stomach
contents, and rarely you will see pulmonary air leaks and decreased cardiac output.
BiPAP is not intended for full ventilatory support.
Your patient must have some spontaneous effort.
BiPAP or CPAP is contraindicated for facial appliances that interfere with facial or neurosurgical
repairs.
Non-Invasive Ventilation Guidelines.
So who gets non-invasive?
Initiations or titrations of CPAP or BiPAP require admission to an ICP or ICU.
Transfers to a non-ICU or non-ICP setting may occur once a patient on CPAP or BiPAP
settings are established using the guideline below.
CPAP or BiPAP may be provided on in-patient units where nurses have received training
and demonstrate competency.
Patients acquiring BiPAP or CPAP who are being transferred to a non-ICU or non-ICP setting
should be clinically suitable as agreed upon by all attending, RN, or RRT.
All patients on non-invasive ventilation must be on a monitor.
Patients that require non-invasive ventilation for 24 hours a day cannot be admitted or transfered
to a non-ICU or floor setting.
All machines used to deliver BiPAP or CPAP in the inpatient non-ICU setting must be connected
to the "Nurse Call"
system. For this reason, patients may not use their home BiPAP or CPAP machines while in the hospital.
Some rules of thumb for the floor, patients cannot be on non-invasive around the clock
unless it's for comfort care measures only.
We cannot wean BiPAP or CPAP settings on the floors, and the only time you can increase
support is in preparation for transfer to an ICU.
Equipment.
So the slide you see in front of you are, are pictures of the Philips V60.
This is what you're probably going to be seeing mostly on the floors.
If you look at the top of the screen, there will be all your alarm settings, and the next
row down are going to be your monitored parameters.
In the middle of the screen will be all of your graphics.
And then in the very bottom, you'll notice that those are the machine's settings.
So the V60's set parameter ranges.
You can set your CPAP level from 4 to 25, your EPAP from 4 to 25, your IPAP can be set
from 4 to 40, the rate can be set from 4 to 60, and the FiO2 from room air to 100%.
Some of the specs on the V60, the battery will last for six hours.
The back of the machine has two holders for oxygen tanks so it's very easy to transport.
It has the ability to go into standby when not in use during the day, so all of your
settings are saved.
It's FDA approved of patients greater than 20 kilos, and anybody less than 20 kilos is
considered to be off-label use.
So Theory of Operation.
With CPAP there's one constant level of pressure that is applied throughout the inspiratory
and expiratory phases of a spontaneously breathing patient.
With BiPAP, there are two levels of positive airway pressure.
One is for the inspiratory phase and then one is maintained throughout your expiratory
phase which is your EPAP.
Some Theory of Operation.
The gas flow rate changes rapidly to affect the cycling between inspiratory and expiratory
pressures in response to your patient's demand.
It will also increase gas flow to overcome any type of moderate leak around the mask.
Exhaled gas is flushed out through an opening in the patient's circuit.
As you can see here, there's one within the circuit and one on top of the mask.
Humidification is also used.
The temperature is set from, usually, 32 to 34 degrees.
Some patients don't like it on.
Patient Interfaces.
There needs to be at least one exhalation port either in the mask or circuit for CO2
removal.
Here you will see a chart of all of our vented and non-vented masks here at Children's Hospital.
We have four types of non-vented masks, and three types of vented masks.
Non-vented masks contain no exhalation ports, so, therefore, the port within the patient
circuit should be used.
Vented masks contain an exhalation port and, therefore, the exhalation port within the
circuit is not needed to be used.
Assessment.
So now you have a patient on BiPAP or CPAP, and you need to do a patient assessment.
A patient on BiPAP or CPAP will continuously monitored with a pulse ox.
CPAP or BiPAP units will be connected to the nursing central monitoring system, and the
respiratory care staff will perform patient and equipment assessment at least twice per
shift.
In coordination, the patient's nurse and respiratory therapist will perform a full skin assessment
at least twice per shift.
For those patients requiring non-invasive at night, skin assessment may be deferred
until patient is removed from device in the morning.
To do a skin assessment you must remove the mask, visualize all contact points of mask
and head gear, and apply a foam dressing to skin such as Mepilex to all contact points,
including the bridge of the nose.
In some cases, you need to alternate between facial appliances of different types.
Finally, you need to have a doctor order.
The physician order for non-invasive should specify BiPAP or CPAP, specific inspiratory
and expiratory pressures, and target sat range for the O2 titration.
Thank you for watching this short video on non-invasive ventilation in the non-ICU setting.
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