1. 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.

7. 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…

8. 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

9. NASAL CPAP

10. Home vs. Hospital

11. 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

12. 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)

13. Goals of NPPV Chronic Care Relieve or improve symptoms
Enhance quality of life
Avoid hospitalization
Increase survival
Improve mobility

14. 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

15. 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

16. 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

17. 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

18. NPPV for OSA
Patients with OSA often use CPAP via face, nasal or nasal pillow masks. Often poorly tolerated.

19. 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…

20. 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

21. 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

22. 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

23. Bipap Typical settings for Bipap:
IPAP 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)
FIO % (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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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.

34. 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

35. Administration of NPPV – Initiation
Select initial settings
FIO2: maintain SpO2 > 90%
Rate: determined by patient, again set low

36. 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

37. 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

38. 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

39. Administration of NPPV – Initiation
Increase expiratory positive airway pressure (EPAP or PEEP) to reduce dyssynchrony from air trapping or to improve oxygenation

40. Administration of NPPV – Assessment
Assessment after initial two hours indicating successful administration
Decrease in PaCO2
Increase in pH
Increase in PaO2
Decreased WOB

41. 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

42. 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

43. 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

44. Side Effects Side Effect Possible Remedy Mask related Discomfort
Facial skin erythema
Claustrophobia
Nasal bridge ulceration
Acneiform rash
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
Air pressure or flow related
Nasal congestion
Sinus or ear pain
Nasal or oral dryness
Eye irritation
Gastric insufflations
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

45. Side Effects Side Effect Possible Remedy Air leaks
Encourage mouth closure, try chin straps, try
oronasal mask if using nasal mask, reduce
pressure slightly
Major complications
Aspiration pneumonia
Hypotension
Pneumothorax
Select patients carefully
Reduce IPAP
Stop ventilation if possible, reduce airway
pressure; insert chest tube if indicated

46. 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

47. Contraindications Absolute Untreated pneumothorax
Patient without a paten airway
Apnea
Inability to fit interface due to deformity

48. Contraindications
Relative
Unstable hemodynamic state
Facial trauma

49. HW assignment Michaines@hotmail.com
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 me your articles or attach them with your paper. Use correct referencing
DUE OCTOBER 8th