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What is BiPAP?
Bi level positive airways pressure. IPAP = Inspired positive airway pressure. EPAP = Expiratory positive airway pressure.
What is BiPAP?
Provides assistance during inspiratory phase AND prevents airway closure during expiratory phase. Normal respiration has 2 phases; inspiration and expiration plus pause. Normal I:E ratio is 1:2 BiPAP alternates between IPAP and EPAP and synchronizes with patients breathing. As patient inspires ventilator delivers IPAP which stops as patient expires but pressure within airways remains positive because of EPAP.
BiPAP delivers CPAP but also senses when inspiratory effort is being made and delivers a higher pressure during inspiration When inspiration + IPAP stop pressure returns to EPAP level
What is IPAP?
As patient breathes in equipment generates positive pressure at the IPAP level set.
(positive pressure = pressure higher than atmospheric pressure).
Autotrack/Trigger (pre-set on Harmony) senses inspiratory effort of 6ml and triggers inspiratory pressure breath by breath. Trigger also senses end of inspiration. Autotrack recognises and compensates for small leaks.
Benefits of IPAP
Reduces CO2 levels / improves CO2 removal. Rests respiratory muscles. Can give O2 without fear of respiratory depression.
EPAP
Continuous positive pressure maintained within the airway also known as CPAP and PEEP (Positive end expiratory pressure). Applies positive pressure at the end of each expiration.
Effects of EPAP
Inflates the alveoli and keeps them open. Increases surface area + so improves alveolar gas exchange. Increases lung volume, functional residual capacity (FRC). Improves oxygenation. Reverses atelectasis as areas of collapsed lung can be reinflated (recruit alveoli). Reduces pulmonary oedema as interstitial fluid is forced back into pulmonary circulation.
Points to remember
BiPAP Harmony
Filters Grey - wash and dry. white - disposable, change when dirty. AC Power Switch Alarm 1: Patient low pressure alarm detects disconnection or excessive leak Alarm 2: Spanner - power or circuitry failure (A job for EME) Inspiratory Rise Time (Comfort Control) The highly technical opening device Anyone got a biro? White Filter (not shown) Ventilator Tubing
EPAP Slide Setting IPAP Slide Setting Not Shown Breaths per minute Inspiratory Time
Synchrony Machine
Display Screen
IPAP/EPAP settings
Start IPAP 8 EPAP 4 Increase by 2cm increments. The difference between IPAP and EPAP is pressure support and must be set at or above level of EPAP. Therefore if you increase EPAP you must increase IPAP. Settings READ AT TOP OF SLIDER.
Pressure Support
IPAP START @ 8 CMS INCREASE BY 2 CMS
PRESSURE SUPPORT = DIFFENCE THEREFORE STARTS AT 4 CMS MINIMUM PRESSURE SUPPORT MUST ALWAYS BE = TO EPAP
Mode
S/T Spontaneous timed. Spontaneous patient triggers all inspirations. S/T number of breaths is pre-set and these are synchronised with the patients breathing activity. If the patient does not initiate a breath within cycle time, the ventilator will trigger the inspiratory phase giving the patient a ventilator assisted breath.
Inspiratory time Ti
Time machine will deliver inspiratory pressure IPAP in. Dictated by BPM. Remember I:E ratio 1:2 Machine will calculate the expiratory time Ti on Harmony Timed Insp. On synchrony
Inspiratory time Ti
eg. BPM = 20 60/20 = 3. This gives 3 second cycle time Divide by 3 (3 parts- 1 for inspiration + 2 for expiration + pause) We want 1 (the inspiratory part) 3/3 = 1. Therefore set inspiratory time at 1.0 Max. inspiration = 3secs.
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Inspiratory Time vs. Expiratory Time Normally set at 1:2 1 part Inspiratory Phase 2 part Expiratory Phase Note 3 Parts in TOTAL
I:E RATIO
Take ONE minute Divide by Breaths per Minute 60 seconds 20 BPM = 3 seconds per breath
Divide each cycle time by number of parts 3 seconds 3 parts = 1 second per part I:E ratio therefore = 1 second Inspiratory phase 2 seconds expiratory phase
Nearly There!
Patients own RR = 30/min set BPM = 15 60/15 = 4 Cycle time = 4 secs 4/3 = 1.3 Set inspiratory time at 1.3
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Timed backup means that if pt does not inspire within cycle time machine will deliver breath Note max inspiratory time is 3 secs
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Harmony
Synchrony
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Harmony settings
On/off Power indicator Battery indicator Internal error alarm - EME Patient, low pressure, disconnect leak alarm
Harmony cycles
IPAP note green lights illuminated on scale and slider Orange light on BPM shows machine breath
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Alarms
Audible and visual. Spanner = power or circuitry a job for EME. Patient low pressure alarm detects disconnection or excessive leak. Machine will compensate for acceptable leak so if problems persist you may need to change the size of the mask.
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power
Enter/confirm button
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Control screen
Rise Time = time to reach IPAP Same as slider on Harmony
3/4
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Control Screen
Note flashing navigation indicator Use up and down to select Range 1-6 (10ths sec.) Same as centre of slider = 3 High RR may need fast time Wheeze may need slow time 1 = fast 6=slow
3/4
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Changing IPAP
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Parameters page
Press enter to select EPAP to change Note navigation indicator flashes Use arrows to make change
1/3
Confirm change
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Press enter to select Inspiratory time Rise time VentRamp (leave OFF)
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Alarms page
Apnoea alarm options OFF 10 sec 20 sec 30 sec 40 sec We suggest 20 sec setting NEVER OFF
1/2
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Modes available PC = pressure control T = timed CPAP S=spontaneous S/T spontaneous timed
Set up page 4 of 4
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Cancelling alarms
Alarm will be audible Also visual light illuminated + written message Press to
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Masks etc.
Mask - correct size sizing guides, smallest possible
- correct placement - correct position Mask types - full face -nasal Straps - too tight = sores - too loose = leaks Tubing smooth bore to prevent air turbulence
nasal
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Oxygen
Machines run on room air need to entrain O2 into the mask (not tubing). Document L/min given Not able to measure with oxygen analyser Observe O2 sats and ABGs Maintain sats >88%
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Complications of NIV
Discomfort. Breathing against pressure. Masks + straps tight + claustrophobic. Poor mouth hygiene, dry mouth. Hypotension reduced venous return. Noise. Pressure sores. Protect bridge of nose, close obs, skilled positioning.
Complications of NIV
Gastric distension. Close proximity oesophagus + trachea. Air swallowed normally but more with NIV. CPAP inhibits air escape through oesophagus. Stomach distension can cause splinting. Nausea/ Flatulence. ?Ng uncomfortable + create air leak.
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Complications of NIV
Non compliance. May create stress which outweighs benefits. Treatment failure (more later).
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