Noninvasive ventilation: Difference between revisions
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Revision as of 20:15, 3 April 2015

Background

Mechanism of Action

  • Augments inspiratory/expiratory pressures throughout a spontaneous respiratory cycle.
    • Recruits compressed alveoli to reduce atelectasis.
    • Prevents small airway collapse during inspiration.
    • Counteracts intrinsic PEEP (Positive End Expiratory Pressure).
    • Decreased both preload and afterload in heart failure exacerbations.
    • Improves lung compliance and V/Q matching.
    • Decreases the work of breathing.

CPAP vs. BPAP

  • CPAP = PEEP = EPAP
  • BPAP = PEEP + (IPAP = Inspiratory Pressure Support)
    • Note: BiPAP is a brand name of one of the BPAP machines. Both names are often used interchangeably.

Indications

  1. CHF
  2. COPD
  3. Asthma
  4. OSA
  5. Pulmonary edema
  6. Pneumonia

Contraindications

  1. Obtunded patients
  2. Uncooperative patients
  3. Vomiting or inability to protect the airway (aspiration risk)
  4. Facial trauma or burns
  5. Facial, esophageal, or gastric surgery
  6. Poor mask fit

Procedure

  1. Prepare intubation equipment in case of BPAP/CPAP failure.
  2. Position the patient in a 30-90° upright position.
  3. Apply the mask.
    1. Select the appropriately-sized mask.
    2. Secure it in place by fastening the Velcro straps.
    3. Note: Some experts recommend allowing the patient to get used to the mask first, PRIOR TO starting the positive airway pressures.
  4. Prepare the patient.
    1. Patients will often require frequent coaching throughout this process.
    2. In moderately anxious patients, consider a benzodiazepine or Ketamine to assist with patient-ventilator synchrony.
  5. Adjust the settings.
    1. For BPAP, begin with an IPAP of 8-10 cm H2O and an EPAP of 2-4 cm H2O.
    2. Gradually titrate upward IPAP and EPAP 1-2 cm every 5-15 minutes with a goal IPAP 10-16 cm H2O and EPAP of 8-10 cm H2O depending upon patient response.
  6. Continue close monitoring.
    1. A doctor, nurse, or respiratory therapist should be with the patient at all times during BPAP/CPAP use.

Complications

  • Skin irritation
  • Nasal bridge pain
  • Mucosal dryness
  • Eye irritation
  • Gastric distention
  • Decreased cardiac output
  • Barotrauma (rarely)

See Also

Source

EMcrit Podcast 19

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