CPAP- BIPAP

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• CPAP- BIPAP
• Sussan Soltani Mohammadi.MD
• Assistant professor
• Shariati Hospital

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• Positive Airway Pressure Therapy
• Application of higher than ambient airway
  pressure during inspiration and/or exhalation to
  improve
• respiratory function

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• Positive pressure applied during inspiration ?
  PPV.
• Positive pressure applied during exhalation ?
  PEEP.

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• Positive pressure applied during spontaneous
  breathing to maintain an elevated baseline
  airway pressure ? CPAP

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Difference between PEEP and CPAP

• PEEP ? elevated baseline pressure during
  mechanical ventilation (during separate mode).
• CPAP ? elevated baseline pressure during
  spontaneous breathing.

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• BIPAP
• Bilevel positive airway pressure? is an
  intermittent CPAP or CPAP with release
• Occasionally described as Airway Pressure Release
  Ventilation (APRV)

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• 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

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• 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.

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• The short expiratory time
• ( time at the low pressure) prevents complete
  exhalation and maintains alveolar distention .

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• When PP is applied to the respiratory system
  (continuously or at end expiration) ? physiologic
  changes occur ? cardio respiratory system.

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Pulmonary effect

1. Redistribution of extra vascular water ? improve
   oxygenation, lungs compliance and vent/perfusion
   matching.
2. ? FRC ? increase volume of patent alveoli at
   lower levels of PEEP and inflation of previously
   collapsed alveoli ? alveolar recruitment at
   higher levels of peep.

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Cardiovascular effects

• ?CO by three mechanism
• ? venous return
• RV dysfunction (ppv increase PVR ? increase RV
  afterload)
• ?pulmonary pressure ? ? RVEDV ?left ward shift of
  interventricular septum ?LV distensibility ?

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Technical application

• Invasively
• Endotracheal tube
• Tracheostomy tube
• 2) Non invasively
• Mask
• Nasal, Oronasal, Full face mask
• Nasal pillow

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The basic equipments required are

• 1) Ventilator
• 2) Ventilator tubing
• 3) An interface connecting the system to the
  patient

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• CPAP
• Commonly is delivered by a tight fitting mask
• With 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

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• patients can not tolerate mask due to
  claustrophobia aerophagia or hemodynamic
  instability ? endotracheal intubation

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Indications

• Respiratory insufficiency has not yet progress to
  true respiratory failure with dyspnea , use of
  accessory muscle
• 2) Ph lt 7.35 , PaCo2 gt 45 mmHg , RR gt 25

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• 3)Treatment of atelectasis (especially
  postoperative)
• 4) Post extubation stridor
• Immediately ? reintubation
• 30 min or later ? is the result of
  laryngeal edema ? CPAP

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• 5) Accelerate the weaning of ventilatory support
• 6)Exaxerbation of COPD ,asthma
• 7) Hypoventilation syndromes (obesity,
  obstructive sleep apnea syndrome)

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• 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 ).

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Contraindications

• Cardiopulmonary arrest or sever hemodynamic
  instability ,life threatening dysrhythmia
• 2) Apnea or need for immediate intubation
• 3) Facial burns , trauma or surgery

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• 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

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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.

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• 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.

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Monitoring

• For leaks around the mask
• Amount of ventilation , ABG (PaO2)
• Physical exam of the patient for synchrony with
  mechanical ventilation

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• patient comfort
• Presence or absence of stress responses
  (tachycardia , tachypnea)
• Degree of accessory muscle use at the bedside

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Unsuccessful treatment

• Rapid shallow breathing
• Continues accessory muscle use
• Paradoxical abdominal respiration

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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.

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Factors necessitating intubation

• 1)Major factors
• Respiratory arrest
• Respiratory pause with gasping or reduced
  consciousness
• Agitation requiring sedation
• Bradycardia with ? consciousness
• Hemodynamic instability (SBP lt 70)

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• 2) Minor factors
• RRgt35(or gt than admission)
• PHlt 7.30 (or lt than admission)
• PaO2lt 60 mmHg
• Increasing encephalopathy

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• Presence of one major factor at any time or two
  minor factors after 1 hour of NIV should lead to
  intubation

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Complications

• Pressure necrosis over the bridge of the nose
• Nasal ,sinus or ear pain at initiation of NIPPV
  (start at low pressure and slowly rise it)
• Nasal congestion and dryness
• Oral dryness

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• Eye dryness and iritation
• Pneumothorax (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)

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thank you