Bipap for HFD

Bipap for HFD

by Nathan Root

​Objectives

• ​Definition of BiPAP

• ​Bilevel vs BiPAP

• ​Set up of BiPAP on Zoll vent.

• ​Equipment.

• ​IPAP vs. EPAP

• ​Different patients and BiPAP

• ​Making it FIREMAN proof.

​BiPAP vs BiLevel

• ​BiPAP is branded.

• ​BiLevel is Zolls term for it.

​What is BiPAP

• ​A form of NIPPV (Non Invasive Positive Pressure Ventilation).

• ​Two forms of NIPPV: CPAP and BiPAP (Bilevel on the zoll vent).

• ​BiPAP: Two different pressures for the different phases of breathing. ie: Inhalation and exhalation.

​Why would I use it?

• ​Supports both phases of breathing specific to disease process, and patient condition.

• ​Less immediate effects on cardiac preload and afterload.

• ​Patients report less anxiety and increased comfortability long term.

​Equipment

• ​ZOLL vent.

• Ventilator circuit.

• ​NonVented mask.

• ​O2 supply.

​SET UP:

• ​C: Connect circuit, Non-vented mask.

• ​O: ON

• ​M: Select "MASK CPAP."

• ​P: No pressure check is necessary, Ensure LC is on.

• ​S: Settings (Fio2, Ipap/Epap,)

​Connect, then turn on..

• ​Scroll to select MASK CPAP mode.

​Switching to Bipap

• ​IN the bottom box.

• ​Highlight CPAP

• ​Scroll till it displays BL

• ​BL = Bipap

​Leak Check

• ​It should default to on.

• ​If it is crossed out like this.

• ​Highlight it and switch LC to the on position.

​Set your settings

• ​FI02 = 100 to start on every patient.

• ​Ipap/epap = Default will be 9/5

• ​TV can not be changed

• ​RR can not be changed

• ​THIS IS HOW YOUR SCREEN SHOULD LOOK BEFORE APPLICATION!!!!

​IPAP vs EPAP

• ​IPAP = Increase Ventilation Efficiency, Decrease WOB.

• ​EPAP= Increase Oxygenation.

• ​Your default is 9/5

• ​We will ask that you start at 10/5 so that these values exist at a 2:1 ratio to begin.

EPAP = PEEP ​

RULES of BiPAP

1. IPAP should always be higher then EPAP. ​

2. ​Whenever you increase EPAP you should increase IPAP. PS will remain the same.

3. You can increase IPAP independent of EPAP. ​

4. ​EPAP not above 10.

5. ​IPAP not above 20.

Approach: Not every Respiratory failure patient is the same. ​EPAP and IPAP will be different for each patient.

​Consider different etiologies of Respiratory failure.

• ​Cannot oxygenate. (CHF)

• ​Cannot ventilate. (COPD)

Cannot oxygenate

• ​Obstruction is typical.

  1. ​CHF

  2. ​Covid/Pneumonia

  3. ​ARDS

  4. ​Atelectasis

​The problem with obstruction patients: ex.CHF

• ​Aveoli less available, because they are filled with fluid.

• ​Physiological SHUNT occurs. Decrease in V/Q relationship.

• PERFUSION of POORLY ventilated aveoli. ​

• ​PRESENTS AS LOW O2 saturation.

​

​

​How do I fix this??

• ​Start: 10/5

• Values will stay at a 2:1 ratio. (ie: 10/5, 12/6, 14/7, ect) ​

• ​Titrate: Values titrate together. Must be done slowly.

• ​IPAP will decrease WOB.

• ​EPAP will improve oxygenation.

​GOAL: Increase overall pressure in the aveoli to force fluid out, while making exhalation easy.

Cannot Ventilate

​Ventilation issues.

1. ​COPD

2. ​Asthma

​The problem with Ventilation issues. COPD

• ​Cannot Exhale appropriate.

• ​Makes inspiration less effective. Decreased TV.

• ​Increasing the CO2 retention.

Problems with exhalation should have lower EPAP. ​

​How do I fix this?

• ​Increasing the IPAP independent of the EPAP. Slow controlled increases. IPAP levels can cause barotrauma.

• ​EPAP stays the same.

• ​Improves ventilation, Improves oxygenation, and decreases co2 retention.

• ​Use in conjunction with Bronchodilators, Magnesium.

​How do I fix? continued....

• ​Raise Ipap slowly by 1

• ​​Ie. 11/5, 12/5, 13/5, ect...

​Signs of Success for pts on BiPAP

• ​Improved O2 and appropriate Co2 values.

• ​Decreased work of breathing. That is appropriate. (above 12, and below 30)

• ​Stable BP.

​Contraindications

• ​Apnea.

• ​Vomiting.

• ​Excessive secretions.

• ​Hemodynamically Unstable.

​Fail safe....

• ​APNEA ALARM ON THE VENT.

• ​If your pt stops breathing the vent will switch into manual ventilation modes and start ventilating the pt.

• Place and OPA and consider advanced airway placement.

​Keys to Success.

• ​Start slow.

• ​Initiate early.

• ​Introduce it and coach your pt.

• ​Any changes in starting values should be small with re evaluation.

• ​Take a partner.

Questions? ​

​

Ok, Lets do some scenarios. ​

Multiple Choice

This patient calls for Shortness of breath. States shortness of breath x 3 hours since awoke this morning, increased shortness of breath with activity. Has not taken his Furosemide in 3 days. ABCS: Airway is unremarkable, Breathing is elevated rate with shallow respirations, LS are rales bilateral, and radial pulses are rapid with cyanosis noted around the pts face. VS are as follows: BP 230/130, HR 110 ST, Spo2 74% percent, Etco2 is 30 with a RR of 45. 12 lead is unremarkable. Afebrile at 97.4. The decision to move this patient to Bipap is made. What are your starting values? 

• 9/5

• 13/5

• 10/5

• 12/8

Multiple Choice

Bipap is improving your pt. New VS after 5 mins and high dose nitro are 200/104, Hr is 106, SPo2 is 88, and RR is 30. To improve your Spo2 what should your next set of values (IPAP/EPAP) be?

• 11/5

• 12/6

• 14/9

• 13/6

Multiple Choice

This patient calls for Shortness of breath. Pt reports sob for 5 hours. Stated hrx of COPD. Stated multiple breathing treatments pta, and raised home o2 to 6 LPM. ABCS: Airways is unremarkable, breathing is rapid with exaggerated exhalation, wheezing heard on expiration in all fields, radial pulses are present, skin is cyanotic around lips. VS: 140/98, HR is 130 ST, RR is 40, with ETCO2 of 56 (Shark fin waveform), spo2 of 61%, temp of 97.1. Bronchodilators, and magnesium are preformed. WOB and spo2 has been unchanged by these treatments. Bipap is implimented, what should your starting values be?

• 10/5

• 13/5

• 12/8

• 10/8

Multiple Choice

Same patient has had remarkable improvement on Bipap. Vs are now 140/70, HR of 120, RR is 30, spo2 is 88. You want to assist his patient in his work of breathing. What should your next set of values be? 

• 12/6 

• 9/3

• 11/5

• 100/8