CPAP- BIPAP Sussan Soltani Mohammadi.MD Assistant professor Shariati Hospital.
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Transcript of CPAP- BIPAP Sussan Soltani Mohammadi.MD Assistant professor Shariati Hospital.
Positive Airway Pressure Therapy:
Application of higher than ambient airway pressure during inspiration and/or
exhalation to improve respiratory function
Positive pressure applied during inspiration → PPV.
Positive pressure applied during exhalation → PEEP.
Positive pressure applied during spontaneous breathing to maintain an elevated baseline airway
pressure → CPAP
Difference between PEEP and CPAP:
PEEP → elevated baseline pressure during mechanical ventilation (during separate
mode).
CPAP → elevated baseline pressure during spontaneous
breathing.
BIPAP: Bilevel positive airway
pressure→ is an intermittent CPAP or CPAP with release
Occasionally described as Airway Pressure Release
Ventilation (APRV)
This mode was developed during the late 1980s using the principle of
CPAP.
Allow the clinician to set the two CPAP levels → pressure high at
inspiratory time and pressure low or release pressure at expiratory time
In BIPAP clinician set not only the pressure but also the time spent at
each level.Time high or inspiration and time
low or expiration.When the patient is breathimng
spontaneously, transition of pressure
from higher to lower → tidal movement of gas and subsequent
CO2 elimination.
The short expiratory time( time at the low pressure)
prevents complete exhalation and maintains
alveolar distention .
When PP is applied to the respiratory system
(continuously or at end
expiration) → physiologic
changes occur → cardio respiratory system.
Pulmonary effecta) Redistribution of extra vascular
water → improve oxygenation, lungs compliance and
vent/perfusion matching.b) ↑ FRC → increase volume of patent
alveoli at lower levels of PEEP and inflation of previously collapsed
alveoli → alveolar recruitment at higher levels of peep.
Cardiovascular effects↓CO by three mechanism:
1) ↓ venous return
2) RV dysfunction (ppv increase PVR → increase RV afterload)
3) ↑pulmonary pressure → ↑ RVEDV →left ward shift of interventricular septum →LV distensibility ↓
Technical application 1) Invasively:
• Endotracheal tube
• Tracheostomy tube
2) Non invasively:
• Mask:
Nasal, Oronasal, Full face mask
• Nasal pillow
The basic equipments required are:
1) Ventilator
2) Ventilator tubing
3) An interface connecting the system to the patient
CPAP:Commonly is delivered by a tight
fitting maskWith a continuous gas-flow rate (15-
30 lit/min at a specific FIO2)A reservoir bag, a one way valve, a
humidifier and an expiratory pressure valve
patients can not tolerate mask due to
claustrophobia aerophagia or
hemodynamic instability → endotracheal
intubation
Indications1) Respiratory insufficiency has
not yet progress to true respiratory failure with dyspnea , use of accessory muscle
2) Ph < 7.35 , PaCo2 > 45 mmHg , RR > 25
3)Treatment of atelectasis (especially postoperative)
4) Post extubation stridor: Immediately → reintubation
30 min or later → is the result of laryngeal edema → CPAP
5) Accelerate the weaning of ventilatory support
6)Exaxerbation of COPD ,asthma
7) Hypoventilation syndromes (obesity, obstructive sleep apnea syndrome)
8) Do not intubate patients (who have refused intubation)
9) Acute cause of respiratory insufficiency who require a short
period of ventilatory support until underlying problem can be treated
(pulmonary edema , ARDS , pneumonia , chest trauma ).
Contraindications1) Cardiopulmonary arrest or sever
hemodynamic instability ,life threatening dysrhythmia
2) Apnea or need for immediate intubation
3) Facial burns , trauma or surgery
4) Uncontrolled vomiting or sever GIB and need for airway protection (risk of aspiration)
5) Uncooperative patient (extreme anxiety)
6) Sever ill patient with multi organ dysfunction
Ventilators• Most studies have used pressure cycle
ventilator however volume-cycle ventilator has been used successfully.
• Patients tolerate P.C.Ventilator better.
• Risk of barotrauma and degree of air leak are less than with V.C.Ventilator.
• Types of ventilators have ranged from standard ICU type ventilator
to portable ones designed for CPAP or NIPPV.
• Use of portable pressure-cycle ventilator in ICU provides high
FIO2 levels and lack of alarm or monitors.
MonitoringFor leaks around the mask
Amount of ventilation , ABG (PaO2)
Physical exam of the patient for synchrony with mechanical
ventilation
patient comfort
Presence or absence of stress responses (tachycardia , tachypnea)
Degree of accessory muscle use at the bedside
Unsuccessful treatment
Rapid shallow breathing
Continues accessory muscle use
Paradoxical abdominal respiration
Successful treatment Conversion of rapid shallow
breathing →slower deeper pattern Exhaled tidal vol ≥ 5-6 ml/kg RR≤ 20 ↓CO2
Improvement of respiratory parameter usually occurs within the
first hours.
Factors necessitating intubation
1)Major factors:Respiratory arrestRespiratory pause with gasping or
reduced consciousnessAgitation requiring sedationBradycardia with ↓ consciousnessHemodynamic instability (SBP < 70)
2) Minor factors:
RR>35(or > than admission)
PH< 7.30 (or < than admission)
PaO2< 60 mmHg
Increasing encephalopathy
Presence of one major factor at any time or
two minor factors after 1 hour of NIV
should lead to intubation
ComplicationsPressure necrosis over the bridge of
the noseNasal ,sinus or ear pain at initiation
of NIPPV (start at low pressure and slowly rise it)
Nasal congestion and drynessOral dryness
Eye dryness and iritationPneumothorax (rare but may
occur at high pressure especially in bullous lung disease)
Aspiration especially with full face mask
Gastric insufflation(25% may need NG tube)