INTERDISCIPLINARY CLINICAL MANUAL Policy/ Procedure

Transcription

1 INTERDISCIPLINARY CLINICAL MANUAL Policy/ Procedure TITLE: Non Invasive Positive NUMBER: CC Pressure Ventilation Date Issued: October 2011 Page 1 of 13 Applies To: Respiratory Therapy and Nursing (RN) This is a Post-Entry Level Competency for Registered Nurses and requires assessment of Competency before performing. This is a basic competency for Registered Respiratory Therapists. TABLE OF CONTENTS Policy 1 Definitions 3 Guiding Principles and Values.. 3 Procedure 4 Equipment. 4 References 7 Related Documents. 8 Appendix 1 Vision BIPAP Machine Set up.. 9 Appendix 2 Star Med Helmet. 11 POLICY 1. Non-Invasive Positive Pressure Ventilation (NIPPV) is to be used in conjunction with CC Mechanical Ventilation Initiation Maintenance and Weaning. 2. Care of the patient receiving NIPPV is a shared responsibility between the RRT and the RN NIPPV is a basic competency for the RRT and an advanced competency for the RN 2.2. The RRT sets up NIPPV on the patient and monitors at intervals (the RRT is assigned to designated units with many patients; the RN is assigned to a patient or patients) 3. Initiation of NIPPV requires a physician order.

2 Non Invasive Positive Pressure Ventilation CC Page 2 of Decisions when choosing a method of non-invasive ventilation are done collaboratively with the physician and RRT. 5. NIPPV will be offered to patients at Capital Health for whom it is clinically indicated and in a setting where staff competency includes caring for the mechanically ventilated patient. 6. NIPPV for acute respiratory distress or acute respiratory failure patients will ONLY be provided in the following acute care areas: Medical Surgical Intensive Care Unit (MSICU, 3A, VGH Medical Surgical Neuro Intensive Care Unit (MSNICU, 5.2) Coronary Care Unit (CCU, 6.4) Cardiovascular Surgery Intensive Care Unit (CVICU, 5.1) Emergency Department (ED, Halifax Infirmary Site -HI) Post Anesthetic Care Unit (PACU) Intermediate Care Unit (3IMCU, HI) Burn Unit (4.2 HI) Dartmouth General Hospital (DGH) ICU DGH ED Exception: During an acute respiratory event ONLY, NIPPV may be initiated outside of the above areas to help prevent further deterioration in patient status while arrangements are being made to transfer the patient to the appropriate acute care areas indicated above. 7. NIPPV is to be applied via a traditional mechanical ventilator, a dedicated Bi-level positive airway pressure (BiPAP) or continuous positive airway pressure (CPAP) machine to the chosen interface and not via an invasive artificial airway such as an endotracheal or tracheostomy tube.

3 Non Invasive Positive Pressure Ventilation CC Page 3 of 13 DEFINITIONS Non invasive ventilation: Bi-level positive airway pressure (BIPAP): Expired Positive Airway Pressure (EPAP): Inspiratory Positive Airway Pressure (IPAP): Interface: Peak Airway Pressure: PEEP: Pressure Support (PS): Ventilator Associated Pneumonia (VAP) The application of positive pressure for the purpose of augmenting alveolar ventilation. A two level system of alternating pressures delivered noninvasively via a face mask. Recruits under-ventilated alveoli by increasing lung volumes during expiration. It allows alveoli to remain open during expiration. The pressure set to be achieved at peak inspiration. Devices that connect the ventilator tubing to the patient allowing the entry of pressurized gas to the upper airway. The top airway pressure achieved at peak inspiration Positive End Expiratory Pressure. The amount of additional support that is used to achieve IPAP or Peak Airway Pressure (PAP). Those patients who are intubated or who have a tracheotomy have a greater risk of developing pneumonia. (refer to Safer Healthcare Now VAP Bundle) GUIDING PRINCIPLES AND VALUES 1. Noninvasive invasive ventilation (NIPPV) is an assisted mode of ventilation, intended to augment the ventilation requirements of a spontaneously breathing patient. It is not intended to provide the total ventilatory requirements of the patient, rather to supplement the total work of breathing for a patient. 2. NIPPV can be used in an acute respiratory failure setting or to assist in the management of chronic respiratory disorders. Non-invasive ventilation uses an interface (mask or helmet) to provide temporary ventilatory assistance. Note: Many patients have sleep-disordered breathing, some of which can be treated with non-invasive positive pressure ventilation. Sleep disordered breathing (sleep apnea, hypopneas, and hypoventilation) can develop into or exacerbate ventilatory insufficiency and can complicate other pulmonary diseases (2010 Orlando Heath, Education and Development). This topic has a separate policy (CPAP/BIPAP) and is not addressed in this policy/learning module.

4 Non Invasive Positive Pressure Ventilation CC Page 4 of 13 PROCEDURE Equipment Positive Pressure Ventilator or BIPAP/Vision Face mask or NIPPV Helmet Oxygen Source Head straps Pressure Bulb (if using Helmet) Syringe Heat Moisture Exchange Filter Gloves and other personal protective equipment For acute respiratory failure patients in non critical care areas the following equipment should also be available: o Pulse oximetry o Suction equipment o Airway kit with intubation equipment o Cardiac monitoring Assessment 1. The RRT and Physician assess for the following indications, possible complications and contraindications: 1.1. Indications: Acute respiratory distress situations in which patients are suffering from acute hypercarbic or hypoxic respiratory failure, and where the underlying cause is generally reversible within a relatively short period of time (generally hours to days). Examples: Chronic Obstructive Pulmonary Disease (COPD) exacerbation Cardiogenic pulmonary edema Acute or chronic respiratory failure Atelectasis Short trials to prevent reintubation post-extubation in specific circumstances Facilitate early extubation of spontaneously breathing patients who would normally require extended periods of invasive ventilation as a supplement therapy for respiratory support. Note: This allows for shorter intubation times which may reduce the risk of complications associated with an artificial airway such as airway damage or VAP.

5 Non Invasive Positive Pressure Ventilation CC Page 5 of Complications Similar to those for invasive positive pressure ventilation and include hemodynamic changes (hypotension, cardiac dysrhythmias) and pulmonary barotraumas (pneumothorax) Skin breakdown of the face and nasal bridge due to mask pressure General Contraindications lack of a spontaneous respiratory drive (apnea) inability of the patient to protect their own airway: absent cough/gag, decreased level of consciousness inability of a patient to remove the mask themselves (increased risk of aspiration from vomiting into the mask); patient may not be restrained hemodynamic instability, in particular hypotension cardiac dysrrhythmias uncooperative patients, including the severely agitated and/or delirious patients and/or those complaining of claustrophobia intolerance to the type of NIPPV chosen(from Urden Critical Care Nursing 2010) status asthmaticus (AACN Procedure Manual for Critical Care, 2011) excessive secretions (AACN Procedure Manual for Critical Care, 2011) 1.4. Relative Contraindications patient compliance with wearing the mask inability of the patient to clear own secretions facial trauma nasal and gastrointestinal(gi) bleeding recent surgical repair of the upper GI tract (the positive pressure applied to the mask may enter the GI system as well as the respiratory system) 2. RRT Responsibilities: 2.1. Obtain physician order Explain procedure to patient and family Assess the the patient for: sufficient upper airway function and cough to protect their airway hemodynamic instability Arrhythmias Anything that puts the patient at high risk of aspiration Monitor closely for tolerance (see procedure # 2.14)

6 Non Invasive Positive Pressure Ventilation CC Page 6 of Assemble the circuit as per manufacturer s instructions. (Refer to Appendices 1 and 2) In general, the circuit begins with the ventilator and continues through a low resistance bacteria filter, large bore tubing, oxygen, and the mask with headgear A passover humidifier, pressure tubing and alarm may also be included in the circuit Select the appropriate interface (i.e. face mask or helmet) The mask should be as comfortable and as small as possible to minimize dead space Position the mask so its upper portion rests at the low point where the nose meets the forehead Position the head of the bed 30 degrees or higher, if possible 2.7. Turn the machine on; ensure there is flow Place mask on patient and connect to ventilator 2.9. Adjust settings as initially ordered Observe the patient for excessive air leakage Ensure the patient is connected to continuous pulse oximetery Set appropriate alarms Stay with the patient and provide reassurance and possible mask/ventilator adjustments as the patient gets used to the system Monitor vital signs including blood pressure, heart rate, respiratory rate, oxygen saturation, and cardiac rhythm. Note: Pulmonary barotraumas and pneumothorax may be complications of this therapy Document on Respiratory Monitoring Record Adjust settings to control symptoms while following arterial blood gases (ABG) results If the patient's condition fails to improve within 60 minutes, consult physician as the patient may require endotracheal intubation/invasive ventilation Adjust any ventilator changes/changes/adjustments to the NIPPV interfaces; collaborates with the RN and physician as required Provide on-going patient monitoring along with the RN. 3. RN Responsibilities (Refer to policy statement #2) 3.1. Obtain physician order Explain procedure to patient and family.

7 Non Invasive Positive Pressure Ventilation CC Page 7 of Once the patient is set up by RRT, document patient assessment, parameters and vital signs in the health record Stay with the patient and provide reassurance/ongoing assessment and possible mask/ventilator adjustments (RRT) as the patient gets used to the system Monitor vital signs including blood pressure, heart rate, respiratory rate and oxygen saturation and cardiac rhythm. Note: Pulmonary barotraumas and pneumothorax may be complications of this therapy Collaborate with the RRT and physician regarding required ventilator changes/changes/adjustments to the NIPPV interfaces (as per procedure #2.18) Note: The RN/physician is responsible for ventilator changes at the Dartmouth General Hospital (DGH) at night when no RRT is available. The physician should be notified regarding any concerns with patient monitoring parameters 3.7. Provide mouth care as follows swab sticks q 2-4h using sterile water/saline, tooth brushing q 12h Vaseline to lips as needed. REFERENCES BIPAP Vision, Clinical Manual. Respironic, Inc. Murrysville, Pennsylvania, Clinical Manifestations and Assessments of Respiratory Disease. DesJardins 2002 Clinical Blood Gases 2nd Ed, Malley 2005 CaStar User Guide, StarMed MedicalDisposables,. Mirandola, Italy. St.Mary s General Hospital Non Invasive Ventilation Policy and Procedure, Kitchener, Ontario. DE. O Donnell, P.Hernadez, A. Kaplan, et al. Canadian Thorasic Society Recommendations for the Management of Chronic Obstructive Pulmonary Disease Update. Can. Respir J 2008; 15(Supplement A:1A-8A). Egan s Fundamentals of Respiratory Care 9th Ed, Wilkins 2009 Perry, A.& Potter.P.,(2010) Clinical Nursing Skills and Techniques,7 th Edition. Mosby Elsevier, Toronto, Canada. Perry, A.& Potter.P.,(2010)Canadian Fundamentals of Nursing. Mosby Elsevier, Toronto, Canada. Keenan,S.P., Sinuff,T., Burns,K., Muscedere, J., et al.(2011) Clinical practice guidelines for the use of noninvasive positive-pressure ventilation and noninvasive continuous positive airway pressure in the acute care setting. CMAJ, 183. (E195- E214). Urden, L.D., (2010) Critical Care Nursing, Mosby Elsevier, Toronto, Canada.

8 Non Invasive Positive Pressure Ventilation CC Page 8 of 13 Wiegand,D. L., (2010)AACN Procedure Manual for Critical Care 6 th edition,elsevier Saunders, St. Louis, Missouri. RELATED DOCUMENTS Policies CC Mechanical Ventilation Initiation, Maintenance and Weaning Forms Respiratory Monitoring Record CD0279MR Appendices Appendix 1 Vision BIPAP Machine Set-up Appendix 2 Star Med Helmet * * *

9 Non Invasive Positive Pressure Ventilation CC Page 9 of 13 Appendix 1 Vision BIPAP Machine Set up 1. Plug in machine to power and oxygen 2. Connect BIPAP circuit to the front of the machine and connect the pressure cable to the pressure nipple on the front of the machine 3. Turn on the machine at the white switch on the back of the machine(right hand side) 4. Perform the self test as instructed on the screen 5. Once self test completed, select the MODE: CPAP or Spontaneous Time(S/T) - this mode will give the patient a pressure limited time cycled breath if the patient fails to initiate an inspiration within the interval determined by the rate control 6. Press the parameters button and set the IPAP, EPAP, FIO2, rate, timed inspiration, IPAP Rise Time as per orders. These are set by pressing the soft key corresponding with the parameters you wish to set, when the parameter is highlighted turn the knob to modify the selected parameter. 7. Ensure all parameters and alarms are set. 1. The rate should be set at the expected minutely rate 2. The rate control and the Timed Inspirations are linked so that the inspiratory time is never longer than the expiratory time or greater than 3 seconds. If the rate is increased to a value that would exceed a 1:1 ratio, the timed inspiration value is automatically reduced to maintain a 1:1 ratio 3. The inspiratory time and the rise time % should be adjusted as per the patient s comfort and tolerance of the non invasive ventilation 4. Hi Pressure 2 above set IPAP 5. Lo Pressure 2 below set IPAP 8. Connect to the patient 9. Ensure all documentation is carried out

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11 Non Invasive Positive Pressure Ventilation CC Page 11 of 13 Appendix 2 Star Med Helmet Restrictions for Use 1. The device may be used continuously for a maximum of 7 days after which it must be replaced. 2. RRT responsible for choosing the correct size based on the neck circumference indicated on the label. Suitable choices will insure a good seal around the patient s neck. Adult sizes are XS- S- M- L- XL. Possible Side Effects Axillary pain Skin breakdown (underarms) Claustrophobia CO2 Retention with rebreathing Increased temperature inside helmet Procedure for Use Remove the device from the package and restore the cylindrical shape. Open and close the access port to ensure it is in working order. 1. Arrange the fastening straps securing them on the rear of the hood. 2. Connect the ventilator circuit to the inspiratory and expiratory connectors. 3. Activate the ventilation flow before continuing to ensure pressurization of the hood. 4. Open the collar and place it over the patients head. Have 2 people do this by gripping the flaps in a diametrically opposite way. 5. Position the straps under the arms and fasten them to the front of the hood. Keeping the rigid link about 1cm above the shoulders. 6. Inflate the internal cuff using a cuff inflation pump and clamp. 7. Pressurize the system by pulling the pressure knob until desired pressure is reached. The valve will go into patient safety mode if the internal pressure drops below 2cmH2O pressure. Note: need to re-pressurize after any opening of the access port. 8. There are sealed accesses on the rigid ring for catheter insertion (3, 5 and 7mm). Turn the nut and slide the catheter through locking to provide airtight access. After use, close the cap to ensure hermetic seal of the system. 9. Adjust ventilator settings as appropriate and document. How to Remove the Hood 1. Remove any catheters from the access ports. 2. Deflate the internal cuff by opening the clamp. 3. Detach the fastening straps. 4. Remove the hood by opening up the collar with 4 hands. 5. Turn off the ventilator. Precautions

12 Non Invasive Positive Pressure Ventilation CC Page 12 of Single patient use. 2. Device contains metals, not for use in MRI. 3. During therapy patient may complain of noise caused by the high flows utilized. The noise may be reduced by wearing ear plugs or adding filters to the inspiratory and expiratory connections. 4. Internal pressure of the hood can increase. Be aware and ensure there is adequate flow to reduce the occurrence. 5. Internal temperature of helmet can increase. Be aware and ensure there is adequate flow to reduce the occurrence. May need to discontinue. Copyright Capital Health (2011); contact

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