NHS FORTH VALLEY
BIPAP Guideline
Date of First Issue 27 / 10 / 2010
Approved 27 / 10 / 2010
Current Issue Date 27 / 10 / 2010
Review Date 27 / 10 / 2012
Version Version 1.00
EQIA Yes 27 / 10 / 2010
Author / Contact Dr Morrison
Group Committee – Final Approval
NHS Forth Valley
Consultation and Change Record
Contributing Authors: Dr Morrison, Dr Newman, Dr Hawkins, Clare Colligan-Respiratory pharmacy
Consultation Process: As above
Distribution: Acute clinical guidelines on intranet
Change Record
BIPAP GUIDELINE
RING MEDICAL HIGH DEPENDENCY UNIT FOR BIPAP ASSESSMENT AND PROVISION
If you feel you have a candidate for BiPAP please contact MHDU Ext 4422 and a member of the BiPAP nursing team will come and assess your patient-please make sure you have considered the questions in the Quick Reference Guide first however.
Please note-this guidelines applies to the acute use of BiPAP. From time to time patients on long term non invasive ventilation will be admitted acutely for other reasons. The primary reason for their admission should determine whether or not they require a Critical Care bed and if not they may be nursed on the appropriate ward. Any trained carers should be invited to stay with the patient to facilitate their management.
Factors to take into account if considering BiPAP or IPPV
1. Does the patient have an advance directive or advance care plan?
2. Does the patient have a COPD alert card to help guide initial O2 therapy?
3. What is the patient’s exercise tolerance when stable? 4. What ADL’s can the patient perform when stable? 5. What is the patient’s QOL when stable?
6. What reversible factors are there?
Do not use BiPAP to delay intubation in those who clearly need it.
Indications
The patient must have COPD with all of the following despite maximal medical treatment including controlled oxygen;
SOB RR > 24
PaO2 < 7.5 kPa
PaCO2 > 6.0 kPa
H+ > 45
i.e. Decompensated Type II respiratory failure
If PaO2 < 6.0 kPa or H+ > 60 consider IPPV unless BiPAP is the ceiling of treatment
Contraindications Absolute Acute asthma Facial trauma/burns Recent surgery • Facial • Airway • Upper GI surgery
Fixed upper airway obstruction Undrained pneumothorax
Relative
Life threatening hypoxia Haemodynamic instability Severe co-morbidity Impaired consciousness Confusion/agitation Vomiting Bowel obstruction Copious secretions Pneumonia Planning/Decisions to be made
• What to do in the event of deterioration • What is the ceiling of therapy
• Who has continuing overall clinical responsibility
Medical management
Ensure management has been verified with the first on Medical Middle Grader and the Consultant Physician on call and is documented.
Ensure the patient is on maximal medical treatment i.e.
• Controlled O2-initially 28% by mask and Venturi attachment
• Antibiotic
o If no consolidation on CXR
Co-amoxiclav 1.2g tds iv (if penicillin allergic Clarithromycin 500mg bd iv)
o If consolidation on CXR
Community acquired-treat as for CURB-65 score > 3-see link below Hospital acquired (developing more than 48 hours after hospital
admission)-see link below
• Bronchodilators-Combivent one nebule qds plus salbutamol 2.5mg nebulised prn via compressor with supplemental O2 via nasal cannulae aiming for SaO2 88-92%
• Steroid-prednisolone 40mg oral od or hydrocortisone 50mg iv qds
Repeat ABG within 1 hour to ensure that patient still fits criteria.
Starting BiPAP
If patient still fits criteria arrange rapid transfer to MHDU for trial of BiPAP Inform Intensive Care team and request A-line insertion
Check equipment for integrity before use Attach bacterial filter to ventilator outlet Clean external surface of ventilator
Request that patient sits in bed or chair at > 30o angle
Encourage patient to hold mask in front of face first, before applying straps
Avoid excessive strap tension
Should be able to get 1-2 fingers under strap
Set initial airway pressures
• IPAP 10 • EPAP 4
• Set back up rate at 4 breaths per minute
• Set Ti at 1.0 sec (this will only apply to the preset breaths)
• Set slow ramp initially simply to aid tolerance then steep ramp as patient will be tachypnoeic
Gradually increase IPAP to 12-20 to reduce SOB and RR Entrain O2 as needed and maintain SaO2 88-92%
Humidification is not normally necessary
Continue BiPAP as much as possible during the first 24 hours or until improving Monitor SaO2 continuously for at least 24 hours
As patients may be well oxygenated but have dangerous hypercapnoea and respiratory acidosis check ABG regularly
Give patient breaks as this allows normal eating, drinking and communication. Intermittent use allows nebulisers, physiotherapy, expectoration and gradual weaning
Monitoring
Assess response to treatment and review regularly • Oxygen saturation
• Heart rate • Respiratory rate • Patient comfort • Conscious level
• Accessory muscle recruitment should decrease • Chest wall movement should increase
Troubleshooting
1.Respiratory effort not coordinating with ventilator
Consider;
• Intolerance due to inappropriate ventilator settings • Inadequate pressure
• Leaks from mask or mouth • Undetected inspiratory effort • Excessive leakage
2.Air leakage from the mouth
• May be significant particularly during sleep • Leave dentures in place
3.Air swallowing
• May produce severe abdominal distension
• May limit use in patients with recent abdominal surgery-see contraindications • May require a nasal mask to be used
4.Skin ulceration
• May occur particularly over the nasal bridge • Use a barrier dressing
• Do not overtighten
5.PaCO2 remains high
• Maintain SaO2 no higher than 85-90%
• Check for excessive leakage • Check circuit set up properly • Ventilation may be inadequate
o Observe chest expansion o Increase IPAP
• Patient may be rebreathing
o Check expiratory valve patent o Increase EPAP
• Patient may not be synchronising with ventilator o Observe patient
o Decrease IPAP then slowly increase again to find level that patient will tolerate as there is often an upper limit
o Increase EPAP
• Consider invasive ventilation if appropriate 6.PaO2 remains low
• Increase FiO2
• Increase EPAP
Improvement
Reduction and discontinuation of BiPAP usually occurs in line with clinical improvement and agreement/discussion with patient
Pre discharge
• Check spirometry and ABG on air • Consider long term NIV if
o >3 episodes requiring NIV
o Intolerance of supplementary O2 due to CO2 retention
Initiate BIPAP
• IPAP 10
• EPAP 4
Back up rate 4 Ti 1.0 sec
Slow ramp initially then steep Aim SaO2 88-92%
Initially up to 3 litres O2
Increase IPAP gradually as tolerated over 30 – 60 mins Increase by 2 every 5 – 10 minutes to 12 - 20 to reduce SOB and RR
Repeat ABG’s within 1 – 2 hours
If signs of improvement: i.e. falling H+ and PCO2, rising PO2
Continue present settings
If NO signs of improvement: i.e. rising H+ and PCO2, falling PO2
Adjust settings:
Increase IPAP for rising H+ and PCO2
Increase O2 + EPAP for falling PO2
SIGNS OF IMPROVEMENT?
Once clinically stable introduce breaks
If on maximal settings, refer to ITU - IF APPROPRIATE AIM: Resp rate < 24 bpm Heart rate < 110 bpm H+ < 45 SaO2 88-92%
AUDIT RECORD
Patient’s name: Hospital number:
Date of admission to hospital: Time of admission to hospital: Date of admission to critical care: Time of admission to critical care: Date BiPAP started:
Time BiPAP started:
Q1 Sex: M F
Q2 Date of Birth:
Q3 Diagnosis: COPD
Type 2 Respiratory failure Q4 Performance status:
Normal activity without restriction
Strenuous activity limited, can do light work Limited activity but capable of self care Limited activity, limited self care
Confined to bed/chair, no self care No record
Q5 Focal consolidation on CXR: Yes No No record Q6 Arterial/capillary blood gases :
Q7 Recorded decision on action to be taken if NIV fails: YES / NO (delete which does not apply)
Q8 Place where NIV initiated: HDU ICU Other
Time No record FiO2
% or l/min. PaO2 PaCO2 H+ On admission After 1 hour of maximal medical management After 1-2 hours of BiPAP After 4-6 hours of BiPAP Pre-discharge
Q9 Outcome of NIV:
Success/improved Failure/no benefit
Reasons for failure:
• Intolerance of mask • Excessive secretions • Nasal bridge erosions • Other:
Tracheal intubation Yes No Q10 Complications of NIV:
Q11 FEV1: Not done litres % predicted Q12 Outcome of admission:
Discharged from hospital without NIV Discharged from hospital with home NIV Died-likely cause of death respiratory Died-likely cause of death non-respiratory Other:
Q15 i Duration of BiPAP:
• No of hours used per day • Settings obtained ii Length of critical care stay:
iii Length of hospital stay:
