This BiPAP/CPAP protocol for setup, management and weaning was well received by the medical staff.
Title: BiPAP/CPAP Protocol
EFFECTIVE DATE:__________________ APPROVED:___________
The MD, or the RCP (pursuant to the MD’s medical order for respiratory therapy to follow the BiPAP/CPAP protocol), shall determine BiPAP/CPAP settings based upon each patient’s diagnosis and immediate clinical demand.
The objective is to facilitate the emergent application, management, and timely discontinuation of BiPAP/CPAP therapies via facemask.
The following guidelines transcend the solely physician driven approach to BiBAP/CPAP therapies, thereby allowing the RCP to make timely, necessary adjustments to manage the patient’s immediate clinical demand as his/her condition changes.
Definition of terms
CPAP (Continuous Positive Airway Pressure) delivers a single, constant pressure during both inhalation and exhalation.
BiPAP (Bi-level Positive Airway Pressure) or NPPV (Noninvasive Positive Pressure Ventilation) delivers two pressures. The lesser pressure, referred to as ePAP (Expiratory Positive Airway Pressure), is delivered upon exhalation. It is very similar to, and can achieve the same objective, as CPAP. The second and greater pressure, referred to as iPAP (Inspiratory Positive Airway Pressure) is delivered during inhalation.
Objective of CPAP/ePAP in Acute Respiratory Failure
CPAP/ePAP is generally employed to achieve one of two objectives: (1) to splint the upper airway as a treatment for sleep apnea; or (2) to augment oxygenation in the presence of refractory hypoxemia (i.e. PaO2 < 60mm HG, or SaO2 < 90% with FiO2 > 60%). Our concern in this protocol is with the second objective, the treatment of refractory hypoxemia. This form of respiratory failure is generally cased by a ventilation/perfusion mismatch; which is often observed in such conditions as CHF, atelectasis, pulmonary embolism and pneumonia. CPAP/ePAP treats refractory hypoxemia by increasing and maintaining alveolar pressures, which in turn promotes alveolar recruitment and oxygen diffusion.
Objective of BiPAP in Acute Respiratory Failure
BiPAP may be employed to treat acute or pending respiratory failure. Because iPAP—the greater pressure of the two—augments ventilation, BiPAP can be an effective treatment for acute hypercapnia. COPD, multiple rib fractures with a flail segment or even extreme pain secondary to a post-operative incision are common causes of acute hypercapnia.
Because ePAP—the lesser pressure o the two—is similar to CPAP pressure, BiPAP can also be used to treat refractory hypoxemia, with the additional bonus of assisting ventilation if necessary.
When treating acute hypercapnic respiratory failure, the distance between the iPAP and ePAP pressures is of primary importance. Ventilatory assistance increases as the distance between these two settings widens. For example, an iPAP/ ePAP of 16/6 provides greater ventilatory assistance than does 12/6, whereas both settings provide the same degree of oxygenation augmentation, because both 16/6 and 12/6 have ePAP settings of 6 cm H20.
Contraindications to CPAP/BiPAP Therapy
The following conditions are contraindications for CPAP/BiPAP therapy:
The following conditions may be contraindicated to CPAP/BiPAP therapy, so that the risk versus benefit of ventilatory assistance should be considered:
Selection of Therapy
To determine the therapeutic objective, answer the following questions. What is being treated: Acute hypercapnia? Refractory hypoxemia? Or both?
All settings are considered dynamic, in that they may need adjustment to meet patient demand as his/her condition changes. The following guidelines provide a standardized basis from which to initiate settings and make said changes.
CPAP/ePAP settings for Refractory Hypoxemia
Management and Weaning from CPAP/ePAP with refractory hypoxemia
BiPAP settings for Acute Hypercapnia
Management and Weaning from BiPAP
Flow and Alarm Settings
Begin with a default Rise Time of 0.1 sec and a default Timed Inspiration of 1.0 sec. Adjust as needed to meet patient demand. Back up Rate of 10 to 12 BPM.
All alarms should coincide with patient’s parameters. For example, Hi P = 5 cm H20 above iPAP, Lo P = 5 cm H20 below iPAP, Lo P Delay = 20 sec. Set all the other alarms as appropriate for each patient: Apnea, Lo Min Vent, Hi Rate, Lo Rate, etc.
Patients on home therapy for Diagnosed Sleep Apnea
For the following reasons, chronic sleep apnea patients being treated for diagnoses other than acute hypercapnic or refractory hypoxemic respiratory failure are encouraged to bring their personal CPAP equipment from home. At which time Biomed is notified to perform a safety check on said equipment.