NHS FORTH VALLEY BIPAP Guideline

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1 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 Group Committee Final Approval Dr Morrison Respiratory unit meeting Version th Oct 2010 Page 1 of 11

2 NHS Forth Valley Consultation and Change Record Contributing Authors: Consultation Process: Distribution: Dr Morrison, Dr Newman, Dr Hawkins, Clare Colligan- Respiratory pharmacy As above Acute clinical guidelines on intranet Change Record Date Author Change Version Version th Oct 2010 Page 2 of 11

3 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 O 2 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 PaO 2 < 7.5 kpa PaCO 2 > 6.0 kpa H + > 45 i.e. Decompensated Type II respiratory failure If PaO 2 < 6.0 kpa or H+ > 60 consider IPPV unless BiPAP is the ceiling of treatment Absolute Acute asthma Facial trauma/burns Recent surgery Facial Airway Upper GI surgery Fixed upper airway obstruction Undrained pneumothorax Contraindications Version th Oct 2010 Page 3 of 11

4 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 O 2 -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 documents/qi/ce_guideline_acutemedicine/empirical AntibioticGuidelines.pdf Bronchodilators-Combivent one nebule qds plus salbutamol 2.5mg nebulised prn via compressor with supplemental O 2 via nasal cannulae aiming for SaO % 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 > 30 o angle Size and use full face mask initially, with co-operation of patient Version th Oct 2010 Page 4 of 11

5 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 to reduce SOB and RR Entrain O 2 as needed and maintain SaO % Humidification is not normally necessary Continue BiPAP as much as possible during the first 24 hours or until improving Monitor SaO 2 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 Version th Oct 2010 Page 5 of 11

6 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.PaCO 2 remains high Maintain SaO 2 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.PaO 2 remains low Increase FiO 2 Increase EPAP Consider invasive ventilation if appropriate Version th Oct 2010 Page 6 of 11

7 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 O 2 due to CO 2 retention Any patients with additional needs will be addressed on a one to one basis. Version th Oct 2010 Page 7 of 11

8 PROTOCOL FOR ADJUSTING BIPAP SETTINGS Initiate BIPAP IPAP 10 EPAP 4 Back up rate 4 Ti 1.0 sec Slow ramp initially then steep Aim SaO % Initially up to 3 litres O 2 Increase IPAP gradually as tolerated over mins Increase by 2 every 5 10 minutes to to reduce SOB and RR Repeat ABG s within 1 2 hours SIGNS OF IMPROVEMENT? If signs of improvement: i.e. falling H + and PCO 2, rising PO 2 Continue present settings If NO signs of improvement: i.e. rising H + and PCO 2, falling PO 2 Adjust settings: Increase IPAP for rising H + and PCO 2 Increase O 2 + EPAP for falling PO 2 AIM: Resp rate < 24 bpm Heart rate < 110 bpm H + < 45 SaO % Once clinically stable introduce breaks If on maximal settings, refer to ITU - IF APPROPRIATE Version th Oct 2010 Page 8 of 11

9 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 : Time On admission After 1 hour of maximal medical management After 1-2 hours of BiPAP After 4-6 hours of BiPAP Pre-discharge No record FiO2 % or l/min. PaO2 PaCO2 H+ 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 Version th Oct 2010 Page 9 of 11

10 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: Q16 Respiratory OPD arranged : Yes No Version th Oct 2010 Page 10 of 11

11 Version th Oct 2010 Page 11 of 11

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