non-invasive positive pressure ventilation · non-invasive positive pressureventilation 4 ©2015...

Sir Charles Gairdner Hospital

NON-INVASIVE POSITIVE

PRESSURE VENTILATION

SELF DIRECTED

LEARNING PACKAGE

©Sir Charles Gairdner Hospital, 2015 This publication is copyright. No part may be reproduced by any process except in accordance with the provisions of the Copyright Act 1968 or with the prior written consent of the copyright owner.

Non-Invasive Positive Pressure Ventilation

2 © 2015 Sir Charles Gairdner Hospital

For information regarding this learning package contact Centre for Nursing Education + 61 +8 9346 2600 Email: [email protected] Mail: Q Block Sir Charles Gairdner Hospital Hospital Avenue NEDLANDS WA 6009 AUSTRALIA

DOCUMENT TITLE: NON INVASIVE POSITIVE PRESSURE VENTILATION

Date created Document Edition: Date of Revision By whom: January 2005 January 2015 January 2018 Jacqueline Logan Deb Brown Rebecca Stringer

Developed by: Jacqueline Logan: Staff Development Nurse: Respiratory Medicine: Medical Specialties Division Elizabeth Harris: Staff Development Nurse: General HDU Medical Division Contributors: Centre for Nursing Education


© 2015 Sir Charles Gairdner Hospital 3

CONTENTS

SELF DIRECTED LEARNING PACKAGE AIM 4

EXPECTED LEARNING OUTCOMES 4

WORKING THROUGH THE PACKAGE 5

Module 1

ANATOMY, PHYSIOLOGY & ASSESSMENT OF THE RESPIRATORY SYSTEM 6

MODULE AIM 7

LEARNING OUTCOMES 7

ANATOMICAL LANDMARKS 8

PHYSIOLOGY OF THE LUNGS 9

RESPIRATORY ASSESSMENT 13

Module 2

PRINCIPLES OF NIPPV 15

MODULE AIM 16

LEARNING OUTCOMES 16

TERMINOLOGY 17

DEFINITION OF NIPPV 17

WHAT DOES NIPPV DO? 17

HOW DOES IT WORK? 17

ADVANTAGES AND LIMITATIONS OF NIPPV 19

Module 3

NURSING MANAGEMENT OF NIPPV 22

MODULE AIM 23


PRE-COMMENCEMENT OF NIPPV 24

PROCEDURE 25

Module 4

INTERPRETATION OF ABGS 31

MODULE AIM 32


FOUR STEPS TO INTERPRET ABGs: 35

REFERENCES 43



SELF DIRECTED LEARNING PACKAGE AIM

Welcome to the Non Invasive Positive Pressure Ventilation (NIPPV) Self-Directed Learning Package (SDLP)

This learning package is designed to facilitate your learning in the application of Non Invasive Positive Pressure Ventilation therapies and their associated nursing management

There are 4 learning modules in this SDLP:

• Anatomy, Physiology & Assessment of the Respiratory System

• Principles of NIPPV

• Nursing Management of NIPPV

• Interpretation of Arterial Blood Gases

EXPECTED LEARNING OUTCOMES

On completion of this package you should be able to: • Describe NIPPV and its different

modalities

• Identify the indications for NIPPV

• Identify the benefits of

NIPPV

• Recognise NIPPV equipment

• Describe how to assess and monitor a patient

receiving NIPPV

• Describe possible complications of NIPPV

• Perform a simple interpretation of Arterial Blood

Gas results

• Describe acid-base homeostasis and its physiological importance



WORKING THROUGH THE PACKAGE

Modules in the package provide information on understanding and managing Non Invasive Positive Pressure Ventilation. Two symbols appear in this booklet to direct your progression through the package.

Recommended Reading Directs you to read related journal articles, included with this package. By reading these articles you will be able to answer the review questions contained in each module.

Activities Directs you to an activity that allows you to apply what you've just read. You can write your answers to the activities in this package in the spaces provided. The answers to all questions are provided at the end of the SDLP.



MODULE ONE

ANATOMY, PHYSIOLOGY &

ASSESSMENT OF THE

RESPIRATORY SYSTEM



MODULE AIM

This learning module provides an overview of the anatomical landmarks,

physiological workings and nursing assessment of the respiratory system to

understand the management of patients requiring NIPPV.

LEARNING OUTCOMES

At the end of this learning module, the nurse should be able to:

• Recognise the principal structures of the respiratory system

• Understand why and how we breathe

• Demonstrate an understanding of the steps required carrying out a

respiratory assessment.

Recommended Reading

An Anatomy & Physiology text will be useful in this module



ANATOMICAL LANDMARKS

It is essential to have a sound level of knowledge of the anatomy and physiology of the

respiratory system in order to understand the physiological processes within the

Respiratory System.

This knowledge will then assist in your ability to carry out an effective Respiratory

Assessment when required.

Activities

Q1 Research an appropriate online resource and review you’re knowledge of the anatomy

of the respiratory system. You may need to access Anatomy and Physiology texts or web

based resources to assist you.

Useful Links

ClinicalKey Respiratory Medicine

CE Respiratory Assessment Nursing CEU

Please review the CNE Respiratory Assessment e-learning package link below

PA (Ctrl + click link)

https://www-clinicalkey-com-au.qelibresources.health.wa.gov.au/

http://www.rnceus.com/resp/respframe.html

http://chips/nursing_services/centre_for_nursing_education/eLearning/Physical%20Assessment/Respiratory/player.html



PHYSIOLOGY OF THE LUNGS

How we breathe: Ventilation

Ventilation refers to the movement of air in and out of the lungs. Muscle movement controls

ventilation. The diaphragm is the main muscle for inhalation.

Activity

Q2. Select the correct answers in the following paragraph:

During inhalation, the diaphragm flattens and the ribcage expands. This increases the volume of

the lungs. The intrapleural pressure is lowered below/raised above the atmospheric pressure

so that air is sucked into the lungs.

On exhalation, the diaphragm is raised and the ribcage narrows. This increases/ decreases the

intrapleural pressure above atmospheric pressure, pulling air out of the lungs.

The respiratory control centre, in the ………………………………………….. controls movement

of the diaphragm.

Neural controls of Respiration: How Do You Know How Often to Breathe?

1. Neural

a. Medulla: regulates respiratory rate and depth

b. Pons: is the pacemaker of respiration. It regulates the rhythm and assists in a smooth

transition from inspiration to expiration.

c. Apneustic center: initiates inspiration.

d. Pneumotaxic center: inhibits inspiration by blocking apneustic center transmissions.

2. Mechanical Control

a. Stretch receptors: Nerve endings in the bronchial walls that sense lung inflation

b. Irritant receptors: nerve endings located in the lining of the airways that sense noxious

stimuli, that is, bronchial irritants and inflammation

c. Juxtacapillary receptors: nerve endings in the alveoli and interstitial space that sense

increases in interstitial volumes and pulmonary capillary pressure caused by inflammation

or excessive blood volume in the right heart. Stimulation can cause bradycardia,

hypotension, and constriction of the glottis.

d. Chest wall receptors: nerve endings in the intercostal muscles that sense stretching of the

chest wall. They assist in the regulation of action and timing of respiratory muscles



3. Chemical Control

a. Chemical chemoreceptor: located in the anterior medulla and sense changes in pH in the

extracellular fluid (ECF)

b. Peripheral chemoreceptor: located in the aortic and carotid bodies and send changes in

PO2. They also play a minor role in sensing PCO2. (Greiger-Bronski & Wilson, 2008)

Work of Breathing

In normal quiet breathing, muscle contraction occurs during inspiration, and expiration is a passive

process caused by elastic recoil of the lung. Thus under normal resting conditions, muscle contraction

(or work) is required only during inspiration. The work of inspiration can be divided into 3 categories

1. that required to expand the lungs against lung and chest wall elastic forces, called

compliance work or elastic work

2. that required to overcome the viscosity of the lung and chest wall structures, called tissue

resistance work

3. that required to overcome airway resistance during the movement of air into the lungs

called airway resistance work

During normal, quiet ventilation only 5% of the total energy required by the body is for ventilation

purposes. Exercise, pain and pulmonary disease can increase the work of breathing so that up to 50%

of the body’s energy is used for ventilation (Morton, & Fontaine, 2009, p. 534).

Activity

Q5. Ventilation question:

List signs and symptoms a patient might show who has increased work of breathing?

Respiration: How gas exchange occurs

Respiration refers to the process of gas exchange that occurs at the alveoli-capillary bed. During

inhalation, oxygen passes into the alveoli causing them to inflate. Oxygen diffuses across the alveoli wall,

due to the 02 concentration gradient, into the capillaries surrounding the alveoli.



,

Meanwhile, the blood from the surrounding veins releases its carbon dioxide (C02) into the alveoli.

This movement occurs because of the C02 concentration gradient. The carbon dioxide is expelled

from the body during exhalation (see Figure 1).

Gas exchange facts:

• Gas exchange takes 0.25 seconds.

• At rest, the entire blood volume of the body passes through the lungs each minute (i.e.

5L min).

• The total surface area of the lung is about 100m2 equivalent to the size of a tennis court

• The alveoli wall is less than one millionth of a metre in thickness, to allow for rapid exchange

Gas exchange is affected by the following factors: (Urden, Stacy & Lough, 2010)

Factors Condition

The thickness of the alveoli membrane

The surface area of the membrane

The concentration gradient of 02 and C02 between the alveoli and the pulmonary capillaries.

Perfusion of the lungs



Activity

QG. Each of the factors on the previous table affects gas exchange. Indicate how by selecting a

condition from this list and placing in the table. Some conditions may affect more than one factor.

Pulmonary embolism, pulmonary effusion, pulmonary oedema, pneumonia, asthma,

emphysema and lobectomy, pneumothorax.

You may need to access web-based resources to assist you. Refer to the list of 'Further Resources'

at the end of this module for sites on 'respiratory assessment'

Optimal gas exchange: VQ ratio

Optimal gas exchange requires a matching of air and blood flow (a matching of ventilation and

perfusion) across the alveoli-capillary membrane. 'Normally alveolar ventilation is approximately 4L

min and pulmonary capillary perfusion is approximately 5L min. Thus the normal ventilation

(V) to perfusion (Q) ratio (VIQ) is 4:5 or 0.8.' (Urden, Stacey, Lough,2010)

Activity

Q7. What is the clinical significance of a mismatched V/Q ratio?

The term 'shunting' refers to a situation where the alveoli are being well perfused but are not

being ventilated. Gas exchange is therefore unable to occur.

QS. Suggest two reasons why this may occur.



RESPIRATORY ASSESSMENT

Activity

Access the website on 'respiratory assessment’ CE Respiratory Assessment Nursing CEU

Answer the following questions. Place a circle around the letter that is your answer:

Q9. Which of the following symptoms indicates airflow obstruction and poor ventilation?

a. Intercostal retractions b. Nasal flaring c. Pursed lip breathing

d. All of the above

Q10.Which of the following is not a normal finding on palpation?

a. Asymmetrical chest expansion

b. Tactile fremitus

c. Warm, dry skin

d. No tender spots

Q11.The best description for "bronchial" sounds heard on auscultation would be:

a. Tubular sounds heard in the posterior chest between the scapula: equal

inspiration/expiration

b. Harsh sounds heard over the trachea c. Loud and high pitched sounds; expiratory sounds last longer than inspiratory sounds

d. Soft blowing or rustling sounds heard throughout most of the lung fields

Q12. Which of the following might be observed on inspection of a patient with COPD?

a. barrel chest b. Pursed lip breathing

c. Tripod positioning- body bent forward with arm propped

d. All of the above

Q13. Mr. Green, age 65, is a postoperative patient with atelectasis. You would expect to find all

of the following with respiratory assessment, except:

a. Decreased respiratory rate and decreased pulse rate b. Tactile fremitus decreased or absent

c. Breath sounds decreased or absent on the affected side d. Delayed chest expansion on the affected side

Q14. Wheezes are caused by:

a. Collapsed alveoli

b. Fluid in alveoli

c. Narrowed airways




Utilize the text you are referring to and refresh your knowledge of the following topics. For

your own knowledge write a brief summary for each of these topics.

Q15. Neural Controls of Ventilation

Q16. Gaseous Exchange

Q17. Ventilation & Perfusion

Resources

Lung sounds Auscultation

Breath Sounds - A Guide to Auscultating Breath Sounds

Chest X-ray I n t e r p r e ta t i on

http://lifeinthefastlane.com/drsabcde-of-cxr-interpretation

Chest Radiology

Emergency Department Intranet Respiratory Assessment:


Structure and Function of the lung

http://www.innerbody.com/anatomy/respiratory

http://www.practicalclinicalskills.com/breath-sounds-reference-guide.aspx

http://lifeinthefastlane.com/drsabcde-of-cxr-interpretation

http://www.med-ed.virginia.edu/courses/rad/cxr/index.html

http://wsqe008web/edipprod/edip_pAx_invx_Radiology.asp


http://www.innerbody.com/anatomy/respiratory



MODULE 2

PRINCIPLES OF NIPPV



MODULE AIM

This learning module provides an overview of the principle behind the application of

NIPPV therapy to your patients and the parameters in which it is best utilised.

LEARNING OUTCOMES


• Identify the function and modalities of NIPPV

• Distinguish between advantages & limitations of NIPPV

• Identify indications & contraindications of NIPPV

Recommended Reading Journal Articles Bambi, S. (2009). Noninvasive positive pressure ventilation: An ABC approach for advanced nursing in

emergency departments and acute care settings. Dimensions of Critical Care Nursing, 28(6), 253 – 263. doi: 10.1097/TME.0b013e3181a72818

SCGH library Permalink: https://login.qelibresources.health.wa.gov.au/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=2010485052&site=ehost-live&scope=site De Silva, S. J. (2009). Delivering non-invasive respiratory support to patients in hospital. Nursing

Standard. 23(37), 35-39. doi: 10.1097/DCC.0b013e3181b3ffdc SCGH library Permalink: https://login.qelibresources.health.wa.gov.au/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=2010299261&site=ehost-live&scope=site Wilbeck, J., & Fischer, M. (2009). Noninvasive ventilation in emergency care. Advanced Emergency

NursingJournal, 31(2), 161-169. doi: 10.1097/TME.0b013e3181a72818 SCGH library Permalink: https://login.qelibresources.health.wa.gov.au/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=2010309561&site=ehost-live&scope=site

https://login.qelibresources.health.wa.gov.au/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=2010485052&site=ehost-live&scope=site








TERMINOLOGY

BIPAP Bi-Levelled Positive Airway Pressure (Brand Name)

CPAP Continuous Positive Airway Pressure

VPAP Variable Positive Airway Pressure (Brand Name) NIPPV Non Invasive Positive Pressure Ventilation (BIPAP, VPAP)

IPAP Inspiratory Positive Pressure Ventilation

EPAP Expiratory Positive Pressure Ventilation

PEEP Positive End Expiratory pressure

DEFINITION OF NIPPV

Non-invasive ventilation is defined as ventilatory support without the use of an invasive artificial

airway. In contrast to conventional ventilation, which employs the use of an endotracheal or

tracheostomy tube, NIV provides positive pressure through the use of several different types of

facemasks. Regardless of the type of mask utilized, positive pressure is applied indirectly to the

airways. This positive pressure results in alveolar recruitment and maintenance of the alveoli in an

open position.

WHAT DOES NIPPV DO?

Benefits: maintains positive pressure and thus the volume of air in the lungs between breaths

Increase blood gas oxygenation

Decrease work of breathing by improving lung compliance and therefore reducing respiratory

rate.

Increased FRC (Functional Residual Capacity)- improved ventilation to poorly ventilated or

collapsed alveoli, thereby decreases shunting and improves Pa02

Reduces pulmonary oedema by reducing alveolar collapse and helps redistribute intra-

alveolar fluid

HOW DOES IT WORK?

Consists of 2 levels of positive airway pressure:

IPAP: A positive flow of gas into the lungs. When the patient inspires, the machine assists the

breath to take it up to a constant pre-set positive airway pressure. (Usually between 4-30cm

H20) (Phillips Respironics 2014). IPAP facilitates the removal of carbon dioxide while

decreasing respiratory effort (De Silva SJ (2009) Advantages are increased Pa02, alveoli are

opened with pressure and decrease PC02.

EPAP (Also known as PEEP) recruits under ventilated alveolar and redistributes lung water (De

Silva SJ (2009) It keeps airway pressure above that of atmospheric pressure at the end of expiration.

This assists alveolar gas exchange and distribution of inspired gas (usually between 4-20cm H20).

Modes NIPPV machines can operate in 4 different modes



1. Spontaneous mode

The patient is in control of the respiratory rate. The machine cycles between IPAP & EPAP in

response to the depth of the patients breathing pattern. Not ideal for patients with muscle

weakness as they tire quickly. The patient must trigger a breath to obtain assistance.

The delivered tidal volume will be dependent upon the pressure differential between IPAP and

EPAP levels and the combined resistance to compliance of the circuit and the patient.

2. Spontaneous/timed mode (S/T)

Cycles between IPAP and EPAP levels in response to the patient triggering a

breath. The device augments any breath initiated by the patient, but also delivers

additional breaths should the respiratory rate fall below that of the ‘back up’ breath

rate set on the device by the clinician.

E.g. If the breaths per minute is 10, the respiratory cycle is 6 seconds. If a 6-second interval

passes without a spontaneous trigger, a timed trigger will be initiated. If a spontaneous trigger occurs 5

seconds into the cycle, the timed trigger will NOT occur and the timer is reset for a new 6-second interval.

The patient remains in control of the respiratory rate as long as it exceeds the nominated BPM. The

BPM determines the minimum respiratory rate delivered by the unit.

This setting is ideal for patients who have apnoeic episodes, e.g. post anesthesia. This is also most

commonly used mode for patients with acute or chronic respiratory failure.

3. Timed Mode (T)

In timed mode, the device does not respond to the patient’s respiratory efforts. It cycles between

IPAP and EPAP based solely on the timing intervals determined by the rate of BPM and the

inspiratory time (%1PAP) controls. The %1PAP control determines what percentage of the

respiratory cycle is spent at the IPAP level (average range from 30% - 45%).

Timed mode can prove difficult for the patient to synchronize with and therefore is rarely used today;

however it was used previously for patients with neuromuscular disorders.

4. CPAP Mode

In CPAP mode the patient controls all aspects of the respiratory cycle including inspiratory time

and respiratory rate. The device provides a single level of continuous pressure throughout the

respiratory cycle.

ADVANTAGES AND LIMITATIONS OF NIPPV



Advantages • More comfortable than intubated ventilation

• No need for sedation

• Avoid nosocomial infection

• Permits short breaks so patient can eat, swallow, speak therefore increasing tolerance

• Cheaper to manage out of ICU

• Correction of hypoxaemia without worsening hypercapnia

• Intermittent ventilation possible

Limitations

• Need patient co-operation

• No direct access to airway for suctioning sputum plugs

• Mask pressure may lead to facial ulcers

• Aerophagia

• Conjunctivitis

• Mask uncomfortable , claustrophobic



Indications and Contraindications for NIPPV

Indications

• Acute/chronic hypercapnic respiratory failure (PaC02 > 45mmhg and pH < 7.35)

• Hypoxic Respiratory failure (Sa02 < 80% and/or Pa02 <45mmHg)

• Increased ‘work of breathing’ i.e. Severe dyspnoea with use of accessory muscles,

tachypnoea (resp rate >24/min) paradoxical breathing

• ARDS (Adult Respiratory Distress Syndrome)

• Chronic Obstructive Pulmonary Disorder (COPD)

• Weaning/prevention of intubation

• Pulmonary Oedema

• Chest wall disorders (e.g. Kyphoscoliosis)

• Muscular Dystrophy

• Obstructive Sleep Apnoea

• Hypoventilation in obese patients.

• Cystic Fibrosis

• Ceiling of treatment i.e. patients not suitable for intubation

To treat acute respiratory failure (COPD or CHF)

To palliate for relief of dyspnea or extend survival to settle affairs

Contraindications

• Respiratory arrest, pause or gasping respirations

• Undrained Pneumothorax

• Bullous lung

• Hypotension (systolic BP <70mmHg) due to or associated with intravascular volume depletion

• Severe cardiac arrhythmia's

• Copious airway secretions

• Neurologically impaired patient's

• Unable to maintain own airway

• Facial abnormalities interfering with mask fit

• Active Gastro intestinal bleed

De Silva SJ (2009) Mechanical Ventilation Part II: Non-invasive Mechanical Ventilation for the Adult Hospitalized Patient



Module 2 Review Questions

1. Describe how NIPPV assists ventilation

2. How does NIPPV reverse atelectasis/recruit alveoli?

3. How does it improve oxygenation & reduce the work of breathing?

4. How does it reduce pulmonary oedema? List the 3 steps discussed by (Samy S. Sidhom

Nicholas Hill 2011 p647) in reference to selection guidelines: Noninvasive ventilation for

patients with COPD and Acute Respiratory Failure.

5. List indications for NIPPV



MODULE 3

NURSING MANAGEMENT

OF

NIPPV



MODULE AIM

This learning module provides an overview of the nurse's expected responsibilities when

managing a patient receiving NIPPV.

LEARNING OUTCOMES


• Commence NIPPV therapy

• Demonstrate initiation of correct observation requirements

• Identify essential considerations when initiating NIPPV

• Identify signs of deterioration and able to discontinue NIPPV when indicated

Recommended Reading

Read SCGH Nursing Practice Guidelines No. 69 http://chips.qe2.health.wa.gov.au/NPG/pdf/NIPPV%20(69).pdf Access:

http://chips.qe2.health.wa.gov.au/departments/RespiratoryMedicine/pdf/RHDUBooklet.pdf

Read the following two articles:

Wilbeck, J., & Fischer, M. (2009). Noninvasive ventilation in emergency care. Advanced Emergency Nursing Journal, 31(2), 161-169. doi: 10.1097/TME.0b013e3181a72818

SCGH library Permalink: https://login.qelibresources.health.wa.gov.au/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=2010309561&site=ehost-live&scope=site

http://chips.qe2.health.wa.gov.au/NPG/pdf/NIPPV%20(69).pdf

http://chips.qe2.health.wa.gov.au/departments/RespiratoryMedicine/pdf/RHDUBooklet.pdf





PRE-COMMENCEMENT OF NIPPV

Key Considerations • A consultant or Registrar prescribes NIPPV in consultation with the Respiratory/Pulmonary

Physiology team where appropriate.

• Ensure equipment is correctly assembled (see illustrations}, check with CNS/CN/G54CNS

if unsure.

• Inform patient of the procedure.

• Ensure IPAP, EPAP, BPM, Mode and 02 have been prescribed by the registrar and

documented on the prescription form. Two nurses to check the settings.

• The nurse caring for the patient should be familiar with NIPPV and its use. If not contact

CNS or SDN.

• Assess patients need for insertion of a nasogastric tube. Patients at risk of aspirating

gastric contents or who have been or are at risk of vomiting may require a nasogastric

tube. The NGT should only be inserted if requested by the registrar. Observe for

abdominal distension throughout treatment with NIPPV.



PROCEDURE

• The patient should be specialed until stable or reviewed by CNS.

• Record baseline vital signs including 02 saturation and oxygen supplementation.

• Provide an explanation to the patient and significant others of the benefits of this treatment

and how the mask will be held in place.

• Explain to the patient that it will be difficult to speak once the mask is on. • Set up NIPPV unit and ensure oxygen is connected to circuit.

• Size the patient for the appropriate mask.

• Full-face mask: The mask should comfortably cover the nose and mouth. It should not

cover the eyes or rest below the chin.

• Nasal mask: It should not be so large as to cover any part of the mouth, or so small as to

block the nares

Full Face Mask Nasal Mask

Rg 6 http://resmed.eom.au/portaVsite/ResMedAU/index js pfront_door-true

• Medical/Nursing staff to ensure that the full-face mask is fitted to have the best seal.

• Check for the absence of air leak at interface. Ensure air is not blowing directly into

patient's eyes.

• Once mask is on stay with the patient until they are comfortable tolerating NIPPV.

http://www.google.com.au/url?url=http://www.indiamart.com/sonikamediequip/nasal-mask.html&rct=j&frm=1&q=&esrc=s&sa=U&ei=2lGzVOefHI738QWzhYG4Bw&ved=0CCwQ9QEwCzgo&usg=AFQjCNFphS7dvwTJ71EjBBpewF6hjsWVTw

http://www.google.com.au/url?url=http://www.indiamart.com/sonikamediequip/nasal-mask.html&rct=j&frm=1&q=&esrc=s&sa=U&ei=2lGzVOefHI738QWzhYG4Bw&ved=0CCwQ9QEwCzgo&usg=AFQjCNFphS7dvwTJ71EjBBpewF6hjsWVTw

http://www.google.com.au/url?url=http://www.dothealth.com/Companies/Australia/ResMed-/18071%3Frefcode%3Dfc&rct=j&frm=1&q=&esrc=s&sa=U&ei=tSCRVJzyE87n8AXt-ICwCQ&ved=0CB4Q9QEwBDgU&sig2=0p56p8B-udKBc2h0YHKSaQ&usg=AFQjCNFYvAF-l52HuhsGX85tq821tcAP4A

http://resmed.eom.au/portaVsi



During NIPPV

• Pulse oximetry must be measured continuously during the initial application of NIPPV,

However it may be measured intermittently when patient is stabilized.

• The patient should be nursed in an upright position to assist with ventilation.

• Patients with respiratory failure are often anxious. Reassurance and encouragement will

greatly improve the patients' tolerance of NIPPV.

Observations and Documentation

• Patient observations should be continuous initially and documented every 15 minutes for the

first hour.

• Then as the condition stabilizes, hourly for the first 24hrs and continue 1 hourly thereafter if

patient remains stable.

• If patient's settings are changed at any stage, then document observations 15 minutely for

the first hour and if stable return to hourly observations.

Hourly observations/ documentation include:

• Mode of NIPPV

• IPAP

EPAP

BPM

I:E ratio (only relevant in timed mode)

• Flow rate of supplemental oxygen

• Temperature, blood pressure, pulse rate.

• Respiratory assessment: Rate, rhythm ,air entry

• Conscious level


27

Other Considerations

• Adequacy of mask seal

• Pressure area care 1-2 hourly. Pay particular attention to places where the mask has contact

with the skin, In particular, the bridge of nose.

• Eye care, ensure the seal isn't leaking and blowing air directly into the patient's eyes.

This is to avoid conjunctivitis.

• At the start of each shift check the settings with the nurse handing over.

• Check humidifier bag volume is adequate PRN

• Report and document any significant changes in the patients respiratory and haemodynamic

status to the RMO.

• ABGs are done prior to commencement of BIPAP, within 1hour, 6 hours and 24 hours of

starting NIPPV, daily for the next 24 hours and on occasions if the patient deteriorates.

• Advise patient to immediately report any unusual chest discomfort, shortness of breath, or

severe headaches.

• Ensure Braden Scale re-evaluated due to restricted patient movement.

• Ensure nutrition/hydration requirements of patient are maintained e.g. oral, enteral, IV

Note of Importance

ADVERSE EFFECTS AND COMPLICATIONS OF NIPPV WITH POSSIBLE REMEDIES

Adverse Effect Possible Remedy

Mask-related

Discomfort

Facial skin

erythema

Claustrophobia Nasal bridge ulceration

Acneiforrn rash

Air Pressure or Flow-

related

Nasal congestion

Sinus/ear pain Nasal/oral dryness

Eye irritation

Gastric insufflation

Air Leaks

Major

Complications

Aspiration

pneumonia

Hypotension

Pneumothorax

Check fit, adjust strap, new mask

type Loosen straps, apply artificial

skin Smaller mask sedation Loosen straps, artificial skin, change mask type

Topical steroids or antibiotics

Nasal steroids, decongestant

/antihistamines Reduce pressure if

intolerable Nasal saline emollients, add humidifier, decrease leak

Check mask f it readjust straps Reassure,

simethacone, reduce pressure if intolerable

Encourage mouth closure, try chin straps,

oronasal mask If using nasal mask, reduce pressures slightly

Careful patient

selection Reduce

inflation pressure

Stop ventilation if possible, reduce airway pressure if not

Thoracotomy tube if indicated

(Sidhom & Hill, 2011)


28

Evidence of Deterioration

• Deteriorating conscious state

• Increase agitation

• Onset or worsening of headaches

• Increase heart rate

• Increasing oxygen requirements beyond the range prescribed

• Increasing respiratory distress

• Notify RMO if you suspect your patient is deteriorating

• Worsening gas exchange

Discontinuance Criteria

• Onset of any contraindication/exclusion criteria

• Inability to improve gas exchange, dyspnoea, agitation or respiratory distress with trial (not

exceeding 60 minutes)

• Development of conditions necessitating intubation

• Inability to maintain an adequate tidal volume

• Patient request

Removal of BIPAP

Document and monitor 1/2 hourly for 1 hour or as clinical status indicates:

• Respiratory rate, heart rate

• Conscious level

• Oxygen saturation

• Oxygen flow rate and mode of delivery

• Vital signs TPR BP

Sir Charles Gairdner Hospital

Nursing Practice Guideline 69


29

Module 3 Review Questions

Nursing Management Questions:

1. Why is it important to check regularly for air leaks?

2. Describe an instance where you would expect

a. A full-face mask to be in use.

b. A nasal mask to be in use.

3. How would you explain NIPPV therapy to your patient or their relatives?

4. What is SCGH's policy in relation to setting ranges for:

a. IPAP?

b. EPAP?

5. What changes may you see in these observations for a patient commenced on

NIPPV? Give an explanation for each.

a. BP

b. Sa02

c. RR


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6. What are the nursing considerations?

7. Your patient has been receiving NIPPV for some 8 hours now and the medical staff

has requested a change in the ventilator pressures. What is your course of action

once the pressures are changed?

8. Why should there always be an escape valve/exhalation port in place in the circuit or as part of

mask design?

9. Explain the principle behind the inclusion of humidification in the circuit.

10. List 3 signs of deterioration.

11. Respiratory Failure can be classified into 2 groups. Name them and explain the differences.


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MODULE FOUR

INTERPRETATION OF ABGS


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MODULE AIM

This learning module provides the basic steps required to guide you in the interpretation of

Arterial Blood Gas Analysis.

LEARNING OUTCOMES

Aims of this module:

• Identify different types of acid imbalance

• Identify signs and symptoms of these conditions

• Identify who may benefit from NIPPV

• Identify changes that you hope to see in ABGs when NIPPV therapy is effective.

Recommended Reading:

Read the following article

Pruitt, B (2010) Interpreting ABGS: An inside look of your patients’ status. Nursing 2010,

40(7), 31-35. doi:10.1097/01.NURSE.0000383447.25412.d6

SCGH library permalink: https://login.qelibresources.health.wa.gov.au/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=2010702819&site=ehost-live&scope=site




33

Activities

1. In your own words, explain these terms:

pH

PaCO2

HCO3

pO2

BE

Hypoxia

Hypoxemia

2. Blood gases at SCGH are measured in which units?

3. List the normal ranges of the following in human blood.

pH

PaCO2

PaHCO3

PaO2

SaO2

4. Where would you expect the blood sample to be drawn from?

6. What important steps need to be adhered to when obtaining an ABG sample?


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7. True of False

Carbon dioxide is:

A waste product of metabolism

Mixes with bicarbonate to form carbonic acid

Mixes with water to form carbonic acid

Is excreted by the lungs

Is excreted by the lungs and the kidneys

Stimulates the respiratory centre to increase the depth and rate of breathing

Inhibits the respiratory centre to decrease the depth and rate of breathing

9. The stimulus to breathe is reduced by hypercapnea. True or False?

10. What does pulse oximetry measure?

11. List four possible reasons for a false oximetry reading?

1.

2.

3.

4.


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FOUR STEPS TO INTERPRET ABGS:

By following these 4 steps you will be able to identify:

• when your patient has an acid-base imbalance (acidosis or alkalosis)

• what is the cause of the imbalance (respiratory or metabolic cause)

• whether your patient's body is compensating for this imbalance

• and if this compensation is effective (i.e. complete compensation)

STEP 1: Look at the pH value to determine the cause of the

imbalance. If the pH is above 7.45 the cause is alkalosis

If the pH is below 7.35 the cause is acidosis

If the pH is normal but the PC02 and HC03 indicate an imbalance, use 7.40 as your cut off point.

ABG Sample #1

pH

7.26 A pH value of 7.26 is lower the normal range of 7.35-7.45. It

indicates acidosis.

PC02

56 High

HC03

24 normal

Activity

12. Complete this table. Look at these pH results. Is the pH normal? If not, does it

indicate acidosis or alkalosis?

pH Results Normal, Acidosis or Alkalosis

7.50

7.35

7.04

7.48

7.20

7.56


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STEP 2: Evaluate each ABG value

Study this table as you work through the steps below:

ABG value Low Normal Raised

pH Acid 7.35-7.45 Alkaline

PaC02 Alkaline 35-45 Acid

HC03- Acid 22 - 26 Alkaline

Look at this sample ABG result. Each value indicates either acidity, alkalinity or is normal.

ABG Sample #1

pH 7.26

A pH value of 7.26 is lower the normal range of 7.35-7.45. It

indicates acidosis.

PC02 56

A PC02 value of 56 is higher than the normal range of 35-

45. There is an excess of C02 in the body. C02 is

transported in the body by carbonic acid. Therefore, an

excess of carbonic acid also exists. This value indicates

acidity.

HC03 24

A HC03 value of 24 is within the normal ranges.

Activity

13. Using the table above, indicate whether each value indicates acidity, alkalinity or is

normal.

ABG Sample # 2

pH 7.60

PC02 55

HC03 51


37

STEP 3: Find the value that matches the acid base status. If the PC02 matches the pH, the

problem is respiratory. If the HC03 matches the pH, the problem is metabolic.

ABG Sample # 1

pH 7.26 Acidosis.

PC02 56 Acidity.

HC03 24 Normal

In Sample #1 the PC02 matches the pH. The acidosis problem therefore has a respiratory cause.

This patient is in respiratory acidosis.

Activity

14. Based on your assessment of Sample #2 (from Step 2), what is your diagnosis?

ABG Sample # 2

pH 7.60

PC02 55

HC03 51


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ABG Sample #1

pH 7.26

Acidosis.

PC02 56

Acidity.

HC03 24

Normal

ABG Sample #2

pH 7.60

PC02 55

HC03 51

STEP 4: Determine the extent of compensation

The value that doesn't

match the pH

pH

Compensation is absent

when

Normal

Partial compensation

is present when

Abnormal

Abnormal

Complete compensation is

present when

Abnormal

Normal

Respiratory acidosis

Compensation is not present in this patient, as the value that doesn't match the pH (in this

Case HC03) is normal.

Activity

15.

16. Is compensation present in this patient? If so, is it complete or partial compensation?


39

17. Analyze the following samples and state whether there is compensation.

pH pC02 HC03 Analysis

1 7.44 24 16

2 7.38 76 42

3 7.20 25 9

4 7.56 44 38

5 7.35 25 13

6 7.60 25 24

7 7.36 95 49

8 7.55 58 49

9 7.25 76 30

10 7.45 26 18

11 7.37 83 48

Further ABG questions:

18. Low pH can be caused by;

(a) Abnormal bicarbonate

(b) Abnormal carbon dioxide

(c) Each of the above

(d) None of the above

19. Treatment of respiratory alkalosis consists of;

(a) Increasing depth and rate of ventilation

(b) Decreasing depth and rate of ventilation

(c) Administering sodium bicarbonate

(d) None of the above


40

Scenario One:

At 1300hrs, a 17-year-old female is admitted to your ward from E.D. She has been diagnosed

with an acute exacerbation of Type 2 Respiratory Failure, due to non-compliance with CPAP

at home. She has ABGs taken. The results are:

pH 7.3

PCO2 105

PO2 68

HCO3 49.8

SaO2 92.9%

.20. What is your analysis of these ABGs?

Shortly after arriving on the ward, NIPPV is applied lPAP 12, EPAP 5.

ABGs are taken after 1 hr.

pH 7.31

PCO2 96

PO2 63

HCO3 48

SaO2 90%

21 What is your interpretation of these results?

22 Has NIPPV been effective? Explain how you made this conclusion.

23 What would you do?


41

ICU is called to review the patient. They increase NIPPV pressures to 16/6. After six hours,

ABGs are taken again.

pH 7.36

PCO2 80

PO2 93

HCO3 44

24. What is your interpretation of these results?

25. Has NIPPV been effective? Explain how you made this conclusion?

Scenario Two:

A 49-year-old man is admitted to your unit from ED. His diagnosis on admission is

pneumonia,

Type 1 respiratory failure and Acute Renal failure. He has a past history of hypertension.

At 1130 his ABGs are:

pH 7.22

PCO2 31

HCO3 12

SaO2 95%

26. What is your interpretation of these results?

At 0215, his ABGs are:

pH 7.06

PCO2 62

HCO3 17

SaO2 93%


42

27. This patient is taken to ICU and intubated. Why?

28. What factors impact the decision of whether to trail NIPPV or to intubate a patient?

Twenty-four hours after intubation. The patient's ABGs are:

pH 7.36

PCO2 40

PO2 80

HCO3 22

SaO2 99%

29. What do these results tell you?


43

REFERENCES

Bambi, S. (2009) Non-Invasive Positive Ventilation: An ABC approach for advanced nursing in emergency departments and acute care settings. Dimensions of Critical Care Nursing 28(6), 253-263. doi: 10.1097/TME.0b013e3181a72818

Choudhary, S. (2012) Non-invasive Ventilation in clinical practice, pros and cons. Panacea Journal of Medical Science. 2(1) 7-16

De Silva SJ (2009) Delivering non-invasive respiratory support to patients in hospital. Nursing Standard, 23,(37), 35-3. doi: 10.1097/DCC.0b013e3181b3ffdc

Greiger-Bronski, M., & Wilson, D. J. (2008). Respiratory nursing: A core curriculum. New York, NY: Springer Publishing Company, LLC.

Hill Bailey, P McMillan Boyles, C, Duff Cloutier, J Barlett, A, Goodridge, D Manji, M & Dusek, B (2013) Best practice in nursing care of Dysnea. The 6th vital sign in individuals with COPD. Journal of Nursing practice, 3(1), 108. DOI: 10.5430/jnep.v3n1p108

McLafferty, E., Johnstone, C., Hendry, C., & Farley, A. (2013).Respiratory system part 1. Pulmonary ventilation. Nursing Standard, 27(22), 40-47.

Morton, P. G., & Fontaine, D. K. (2013). Critical care nursing: A holistic approach. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Popat, B., Jones, A. T. (2012) Invasive and Non-invasive Ventilation. Medicine 40(6) 298-304 http://dx.doi.org/10.1016/j.mpmed.2012.03.010

Pruitt, B (2010) Interpreting ABGS: An inside look of your patients’ status. Nursing 2010, 40(7), 31-35. doi:10.1097/01.NURSE.0000383447.25412.d6

Sidhom, S.S., Hill, N. (2011) Mechanical Ventilation Part II: Non-invasive Mechanical Ventilation for the Adult Hospitalized Patient. Irwin and Rippe’s Intensive Care Medicine, (7th Edition, Chapter 59, pp 642-658) Lippincott Williams & Wilkins

Tintinalli, J. E., Stapczynski, J. S., Ma, O. J., Cline, D. M., Cydulka, R. K., & Meckler, G. D. (2011). Tintinalli's Emergency Medicine: A comprehensive study guide (7th ed.). New York, NY: McGraw-Hill Professional Publishing

Wilbeck, J., Fischer, M. (2009) Non-invasive ventilation in emergency care. Advanced Emergency Nursing Journal, 31(2), 161–169. doi:0.1097/TME.0b013e3181a72818

Urden, L. D., Stacy, K. M., & Lough, M. E. (2010). Critical Care Nursing: Diagnosis and management (7th ed.). St Louis, MO: Mosby Inc.


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Figures 1-3

Figure 1 Encyclopedia Britannica 2006

Figure 2 Rg 6 http://resmed.eom.au/portaVsite/ResMedAU/index js pfront_door-true

Figure 3 Table 59.6 Mechanical Ventilation Part II: Non-invasive Mechanical Ventilation for the Adult Hospitalized Patient

http://resmed.eom.au/portaVsi


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