Hi Eric.
Hope this is of benefit. I've had some experience with this stuff and
this is what we practise in Australia.
Bi-Pap, or Bi level positive Aiway pressure is indicated in any
situation where there is need for ventilatory support without the need
for invasive ventilation.
This may sound like a bit of an oxymoron, but if you think about it,
it actually makes sense.
In an emergency department, the following criteria apply before
consideration of non-invasive ventilation
Inclusion Criteria
1. MUST have a patent and NON THREATENED airway
2. MUST be concious
3. MUST have an existing (even if insufficient) respiratory drive
Exclusion Criteria
1. Threatened Airway
2. Unable to Cooperate
3. Patient is Apnoeic
4. Patient is in extremis, with severe hypoxaemia, or severly reduced
respiratory drive and deteriorating.
Thinking about patients with respiratory distress as per your
question, those considered for Bipap
Patient that has
-worsening hypoxaemia and/or
-increasing respiratory rate and/or
-decreasing oxygen saturations
AND
- has had maximal noninvasive support e.g Increasing FIO2 via
non-rebreather mask or venturi mask OR
- Has had poor response to non-invasive support OR
These include patients with
Pulmonary Oedema
Chronic Obstructive Airways Disease
Pneumonia
Asthma
Mild Laryngeal Oedema etc
i.e. anything that increases your A-a gap.
All patients on Bi-PAP should be monitored closely, regardless of
aetiology, to assess for improvement in resp rate, PaO2, Pulse
Oximetry etc. There are many complications associated with Bi-Pap.
So this is obviously something that requires pretty close monitoring,
preferably with one on one nursing, and is not something that would be
easily considered on a ward bed. Patients need to be moved to a high
dependancy unit, or some other monitored bed.
There are many other little things with Bi-pap that you have to
consider. You put someone on Bipap if they have a reasonable chance
of recovery.
If someone is 99 years old, with severe heart failure with pulmonary
oedema, with multiple medical comorbities, think twice about Bi-pap.
Ask yourself "will this patient ever come off ventilation if i put him
on it". THis is NOT a cost issue, but a best care issue.
This happens more often that you would believe, in subtle forms. the
old man with metastatic mesothelioma. The lady with severe pulmonary
fibrosis with worsening hypoxaemia. You are not going to cure them
with Bi-Pap
I guess if it was me, and i had no reasonable chance of recovery, and
I was given the option to die around my loved ones, or to die in a
monitored bed with loud noisy machines and tubes stuck everywhere, i
would choose the former. By hey, every one is different.
Hope this helps
Cheers |
