Introduction to BiPAP

Presentation by Lucy Mummery January 2006

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.

main reason for use of BiPAP acute setting

Chronic condition with cough, expectoration, SOB on exertion and airflow limitation. Generally tense, anxious person unable to catch breath. Work of breathing is increased (intensifying fear) vicious cycle of shallow rapid breathing which then increases airway resistance. Reduced alveolar ventilation. Reduced O2 levels.

Acute exacerbation of COPD

main reason for use of BiPAP acute setting

CO2 retention --- respiratory acidosis. Hypercapnia due to; Exhaustion. Inadequate tidal volumes. Plugging of airways with mucus + secretions.

Acute exacerbation of COPD

So, how does IPAP help?

Decreases respiratory muscle effort due to assist in inspiration. Increases tidal volume (breath size) as a result of a reduction in inspiratory effort. Reduces respiratory rate as breaths are more efficient. Reduces dyspnoea, work of breathing + use of accessory muscles. (^O2 consumption) Improves alveolar ventilation.

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

IPAP reduces CO2/ improves CO2 removal. EPAP improves oxygenation.

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

AC Power indicator Battery Power indicator Down Key Standby Key

Red Alarm Indicator Yellow Alarm Indicator Enter Key

Ramp/Alarm Silence Up Key

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

EPAP START @ 4 CMS INCREASE BY 2 CMS

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.

Other settings Breaths

Breaths BPM Breaths per minute. In acute setting set BPM at half patients own RR eg. Pts RR 40/min set BPM @ 20 Bring BPM down as pt improves. Be aware if we set BPM too high we end up ventilating patient.

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

I:E & Ti explained!

Take ONE minute Divide by Breaths per Minute 60 seconds 20 BPM = 3 seconds per breath

The Maths Bit!

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!

Setting inspiratory time

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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Setting inspiratory time

Patients own RR = 20/min set BPM = 10 Safety back up setting = 10 BPM 60/10 = 6 Cycle time = 6 secs 6/3 = 2 Set inspiratory time at 2

Timed backup means that if pt does not inspire within cycle time machine will deliver breath Note max inspiratory time is 3 secs

BiPAP machines currently available at KCH

1 x ITU machine. Last option No alarms

Harmony 3 on site To be located within ECC

Synchrony 3 on site To be located on Mount/ McMaster

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BiPAP machines currently available at QEQMH

Harmony

Synchrony

Using BiPAP Harmony

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Harmony settings

BPM Breaths per minute, respiratory rate Timed inspiration Ti (seconds)

On/off Power indicator Battery indicator Internal error alarm - EME Patient, low pressure, disconnect leak alarm

IPAP Rise time time takes to get to IPAP

Harmony cycles

IPAP note green lights illuminated on scale and slider Orange light on BPM shows machine breath

EPAP green light on slider

Settings at top of slider

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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.

IPAP rise time control

Slider bottom right slow/ fast. Adjusts length of time taken for inspiratory flow to rise to full pressure = IPAP. Comfort control. Ultimately needs to be in the middle. Tachypnoea faster rise time may be needed to ensure full IPAP is reached before expiration. Obstructed airways slower times may be needed to prevent distress.

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Using BiPAP Synchrony

power

Battery indicator Visual alarm indicator

Down selection button

Enter/confirm button

Up selection button On/off Cancel alarm

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Monitoring Screen 1 1/4

Displays what patient is actually getting Mode = S/T spontaneous timed A shows alarm is set 1/4 =first page of 4 Black ball moves from EPAP to IPAP(activity indictor) Seen here at EPAP ...

Monitoring Screen 1 1/4

..and here during IPAP note black ball shows machine triggered breath Will always default back to this screen Light switches off automatically- first button pushed switches back on

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Monitoring Screen 2 2/4

Vte = tidal volume expiration volume of breath size MinVent = minute volume total volume of breathes over a minute Leak ideal 20-25L/min, will tolerate up to 60L/min

Control screen
Rise Time = time to reach IPAP Same as slider on Harmony

3/4

Note selection indicator means you can enter + change Press

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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

Set up screen 4/4

Press to enter parameters

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Parameters Page 1/3

2 columns Pt getting/ what is set 0.5cm settings Press enter to change

Parameters Page 1/3

Navigation indicator flashes

Use arrows to change

and enter to confirm

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

Parameters page 1/3

Same again with respiratory rate !

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Parameters page 2/3

Press enter to select Inspiratory time Rise time VentRamp (leave OFF)

Parameters page 3/3

Leave Volume Ctrl OFF

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Set up screen 4/4

Press enter to look at and set alarms

Alarms page 1/2

Disconnect alarm options OFF 15 sec 20 sec We suggest 15 sec setting

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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

Alarms page 2/2

LowMinVent alarm Initially leave off until we are used to measuring volumes

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Set up page Mode 4/4

Modes available PC = pressure control T = timed CPAP S=spontaneous S/T spontaneous timed

Set up page Options 4/4

Options page 2 of 3 Lockout facility

Set up page 4 of 4

Options page 3 of 3 Options page 1 0f 3 Patient Alarm history Alarm volume

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Cancelling alarms
Alarm will be audible Also visual light illuminated + written message Press to

cancel CLEAR will appear Then need to press enter to confirm

Safety and maintenance

Filters ; At back grey wash and dry white = disposable, change when dirty At front low resistance antibacterial viral filter 3 microns. Change every 24hrs. Not HME. Exhalation port must not be covered. Clean machine with detergent between use

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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

Other masks available

nasal

Full face Potential new mask

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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%

Humidification, nebulisers and battery

Normal humidification as upper airway is not bypassed and lower flow air than CPAP. Water bath humidifiers for long term use. Saline nebs effective Ensure good systemic hydration Take off for nebulised bronchodilators + drugs whenever possible Battery lasts 4 hrs on charge but depends on settings. When it goes red there are 4 mins left. Has 12 hr recharge time.

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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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