SARASOTA MEMORIAL HOSPITAL DEPARTMENT POLICY

PS1006 SARASOTA MEMORIAL HOSPITAL DEPARTMENT POLICY TITLE: NON-INVASIVE POSITIVE PRESSURE (NPPV) VENTILATION (CPAP/BIPAP) Job Title of Reviewer: EFFECTIVE DATE: REVISED DATE: POLICY TYPE: Director, Respiratory Care Services 4/2/1990 11/15 DEPARTMENTAL INTERDEPARTMENTAL DEPARTMENTS PROVIDING NURSING CARE 1 of 8 Purpose: Policy Statement: Exceptions: To provide safe and appropriate respiratory and nursing care for patient on non-invasive positive pressure ventilation (NPPV). NPPV may be indicated in a variety of conditions and settings, it is approved for use on General medical floors with the following guidelines: a. Nasal CPAP/BiPAP. b. Patients who use NPPV at home and are hospitalized for reasons other than respiratory compromise. c. Patients who are on full face mask for Obstructive Sleep Apnea (OSA) at home. d. Patients who are on NPPV for care at end-of-life and have a DNR indicating comfort care only. The physician may collaborate with the family, patient, and the nursing staff and order that the patient be allowed to reside in a non-critical care unit. ALL other patients on full-mask CPAP/BiPAP should be admitted to Critical Care. 1. NICU/Pediatric patients 2. Patients who are hemodynamically stable, and are no longer in Respiratory failure, but require NPPV while sleeping may be considered for transfer from Critical Care to the floor. a. Respiratory Care should trial nasal CPAP/BIPAP prior to transfer per physician order. b. The use of high flow 02 should also be considered, as appropriate, prior to transfer from Critical Care to the floor. Prepared by: Wanda Turner \\smhfile01\paperless\department policies\nursing\nur_patientcare\126_184.doc 11/17/2015

2 of 8 Indications: a. OSA b. Increased work of breathing c. Upper airway obstruction d. Hypercapnia e. COPD f. Hypoxia where positive pressure ventilation with CPAP pressure and alveolar recruitment is necessary. Contraindications: Definitions: Therapy may be contraindicated in patients with the following pre-existing conditions: a. bullous lung disease b. pneumothorax c. pathologically low blood pressure d. severe cardiac arrhythmias or coronary artery disease e. stroke f. seizures g. Pneumocephalus h. Patients who are unable to protect their airway. i. Patients who experience severe claustrophobia may also be unable to tolerate therapy. j. Sinus or middle ear infection k. Vomiting and/or nausea Non invasive positive pressure ventilation (NPPV) is the delivery of mechanically assisted breaths without the application of an artificial airway. The NPPV may be delivered through a full mask, a nasal mask, or a pillow mask. The most commonly used forms of NPPV are: Continuous positive airway pressure (CPAP). This is the continuous delivery of air under pressure to a patient s airway. It is most often used for obstructive sleep apnea. CPAP works as a pneumatic splint to hold the airway open during sleep. Bi-level positive airway pressure (BiPAP). This is the delivery of air through two levels. It provides one level during inspiration, and a slightly lower level during expiration. BiPAP is intended to augment breathing in those patients with spontaneous respirations. BiPAP is not intended to provide for the total ventilator requirements of the patient. The benefits of NPPV include improved alveolar ventilation, avoidance of the need for invasive mechanical ventilation, and a

3 of 8 decreased breathing effort. Procedure: RESPIRATORY CARE 1. Obtain order from physician regarding: a. BiPAP/CPAP parameters b. optional oxygen/pulse oximetry parameters c. duration of therapy (ex: nocturnal use) d. If the patient can be removed from NPPV such as for meals and tests type of therapy patient should be using while off NPPV should be available in patient room. 2. Perform hand hygiene. 3. Identify patient via patient identification band according to SMH Policy 01.PAT.09 Patient Identification 4. Explain the procedure. 5. Bring assembled equipment to patient s bedside and select appropriate mask with a sizing gauge. 6. Connect equipment to electrical outlet and turn power switch ON. 7. Adjust BiPAP/CPAP settings to ordered levels. If the unit does not have a built in blender, connect ordered supplemental oxygen to either the sample port on the mask or to an oxygen enrichment attachment. 8. Connect manometer via oxygen tubing to either sample port on mask or directly to machine, if applicable. 9. Check desired BiPAP/CPAP levels on manometer by occluding the circuit. a. Place mask over patient s nose/face and apply head strap/ Softcap for a snug but comfortable fit. Adjust head gear as necessary until leaks are minimized. If large leaks persist, readjust head gear or try another mask size.

4 of 8 Note: If patient does not tolerate level of BiPAP/CPAP as initially ordered, therapist may try to titrate the level of BiPAP/CPAP from a tolerable level to the ordered level, allowing the patient to acclimate to smaller incremental increases in the level of BiPAP/CPAP. 10. Set alarms appropriately to signal leak, malposition, or disconnect. 11. Set up pulse oximeter with recorder if ordered per Respiratory Care Procedure CTH.016. 12. Effectiveness of therapy should be evaluated (i.e., patient tolerance, pulse oximetry readings, delivered BiPAP/CPAP oxygen settings, absence of gross leaks, presence of apnea, snoring). 13. Document procedure in the patient record. Document in the patient record after initial set up and no less than every 4-6 hours routinely in the ICU. Non-ICU patients will be monitored on a PRN basis by Respiratory Therapy when the patients are using CPAP for nocturnal use. 14. Appropriately charge for therapy administered. WEANING: Reassess the patient as needed in response to: a. changes in physician orders b. changes in patient condition c. response to alarms NURSING CARE: 1. Obtain an order from the physician. 2. If possible, place the patient in a room close to the nurse s station (if not in critical care). 3. Notify Respiratory Therapy (RT). 4. Assemble equipment (as appropriate) (equipment is as needed) a. Pulse oximeter as ordered. b. Oxygen set up if applicable. c. Oral and nasal suction set up 5. Verify patient according to Patient Identification. Inpatient/Outpatient. Policy 01.PAT.09. 6. Explain the procedure and purpose to the patient and the

5 of 8 family. 7. Assess/reassess the patient every four hours and more frequently as the patient s condition warrants. 8. During each shift, provide face and oral care to prevent skin breakdown. 9. Obtain a physician s order when the patient can be off NPPV therapy, i.e. during meals, facial and oral care, tests, and procedures. 10. When removing the patient s NPPV device during meals, facial, and oral care, apply supplemental oxygen as per instruction from respiratory therapy. 11. Keep the head of the bed elevated at least at a 30-40 degree angle, in order to reduce the risk of aspiration. 12. Monitor for air leaks around the mask during each shift. 13. Provide adequate nutrition and hydration. 14. Provide alternative ways of communication. 15. Respond to NPPV alarms in a timely manner, address any immediate needs, and notify respiratory therapy to assess patient and alarm status. 16. Notify RT to set up and administer NPPV. If patient removes NPPV to get out of the bed for the bathroom/etc., consult RT to check equipment. 17. Notify RT of changes in patient s respiratory status. 18. Notify RT of changes in physician s orders. 19. Consult with RT for any troubleshooting. USE OF PERSONAL MEDICAL EQUIPMENT: 1. The use of a patient s personal medical equipment such as CPAP is allowed in limited circumstances: a. The physician orders the use of the patient s own medical equipment. b. The patient knows the correct settings and maintenance of his/her CPAP equipment. 2. Prior to use of the equipment, notify Biomed Engineering Services to ensure safety (refer to SMHCS Policy 00.SAF.18). 3. Notify Respiratory Therapy regarding the patient s use of personal medical equipment. POTENTIAL COMPLICATIONS: The use of NPPV is not without potential problems. The potential problems with the use of the NPPV are: Facial skin breakdown due to pressure from the mask and straps.

6 of 8 Air leaks from masks. Nasal congestion. Eye irritation. Complaints of claustrophobia. Excessive noise from the NPPV equipment. Decreased blood pressure. The continuous positive pressure results in an increase in the intrathoracic pressure, placing mechanical pressure on the heart, which decreases venous return. Decreased blood return to the right atrium causes hypotension. Decreased heart rate is caused by the effect of the CPAP on cardiac sympathetic nervous system. Gastric distention is the result of the positive pressure in the airways that forces air into the stomach. REPORTABLE CONDITIONS: Notify the physician for: Abnormal ABGs. Pulse oximetry below 90% (for COPD patients 88%) or per MD parameters/orders. Marked decrease in blood pressure and heart rate. Active arrhythmias. Altered mental status. Respiratory distress. An increase in the amount of secretions. Gastric distention. Eye irritation. DOCUMENTATION: 1. Vital Signs Flowsheet: Baseline VS (HR, RR, BP, pulse oximetry) before initiation of NPPV, then per MD order. 2. Respiratory Care will document Initiation of NPPV procedure including settings, type of mask, and FIO2. 3. Assessment/Reassessment Flowsheet: Baseline respiratory assessment. Reassessment of the respiratory system approximately every 4-6 hours. 4. Patient Education Record: Education to patients, families, and significant others regarding NPPV therapy, procedure, and equipment. Responsibility: It will be the responsibility of the patient care directors to see that personnel are aware of, and adhere to, this policy.

7 of 8 References: SMH Policy. Patient Identification: Inpatient/Outpatient. (01.PAT.09). SMH: Author. SMHCS Policy. Safety Check for all New Rental and Physicianowned Electronically Operated Medical Equipment. (00.SAF.18). SMH: Author. Lippincott. (2013). Lippincott s Nursing Procedures-6 th edition. (pp. 211-213). Lippincott Williams and Wilkins. Philadelphia: PA. Author(s): Donetta Dangleis, RRT, Manager, Respiratory Benny Kruger, MSN, CCRN, CNN, APN, Critical Care/Hemodialysis Doris Cahueque, MS, RN, CNL, APN, Medical Surgical Division Attachment(s): None

8 of 8 Approvals: Signatures indicate approval of the new or reviewed/revised policy Date 11/9/15 Title: Mark Pellman, Director, Respiratory Care Services Title: Title: Committee/Sections (if applicable): Clinical Practice Council 11/5/15 Vice President/Administrative Director (if applicable): Name and Title: 11/10/15 Name and Title: Jan Mauck, Vice President/Chief Nursing Officer