Transcript BIPAP Changes in Position on Return VT

Charlotte Burns, SRT
Robyn Borkowski, SRT
Kimberly Sizemore, SRT
Shawn Thomas, SRT
Claire Washington, SRT
Support and equipment was provided by
Lone Star- Kingwood College
Respiratory Dept.
We hypothesize that patient positioning does
in fact play a vital role in the delivery of
tidal volumes during bi-level positive
airway pressure.
Will changes in body position affect the
return VT on a healthy adult getting
BiPAP?
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12 healthy test subjects were placed in
supine, semi-Fowlers and high Fowlers
positions while receiving BIPAP at 10/8
cmH20. The tidal volumes was recorded in
different positions.
There was no significant change in tidal
volume with positional changes.
Only two out of twelve subjects had a percent
change greater than fifteen percent.
Patient positioning plays a vital role in the success
of NIPPV. Current guidelines indicate that the
patient should be in an upright sitting position,
or lying down in the supine position with the
head of the bed (HOB) elevated 30 degrees or
greater. Slouching is discouraged because it
impairs diaphragmatic movement, and results
in decreased inspired tidal volumes.
Non invasive positive pressure ventilation
(NPPV) is now a common device used in
hospitals and home care facilities on a daily
basis. According to Mosby's Respiratory Care
Equipment "the first successful use of non
invasive positive pressure ventilation (NPPV)
was recorded as early as the mid eighteenth
century." (Cairo, pg 773).
In the 1940's Motley and colleagues at Belleuve
hospital studied the use of NPPV on patients
with pneumonia, pulmonary edema, near
drowning, Guillain Barre syndrome, and acute
severe asthma. In the 1960's PEEP was used in
the treatment of acuter respiratory distress
syndrome (ARDS). By the 1970's care givers
were able to understand the effects on invasive
ventilation and the lung damage it can cause,
so researchers went back to NPPV.
In the 1980's NPPV became widespread and many
different brands and modes were developed. In
1987 one study showed the successful use of
NPPV in three patients with post infection
muscle weakness and two with muscular
dystrophy. This demonstrated that NPPV
could be used and effective in long term
settings and diagnosis. In 1989 Meduri and
colleagues were successful in avoiding
intubations with the use of NPPV in eight out
of ten patients.
Indications:
 Bi-level positive airway pressure therapy delivers two
different pressure settings for the patient. Patients who
have been treated with BIPAP have breathing disorders
beyond sleep apnea. BIPAP is useful in CHF patients and
many other types of disorders, particularly patients who
have high CO2 retention. (www.ezinearticles.com)
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*Restrictive thoracic disorders, (progressive
neuromuscular disease or severe thoracic cage
abnormalities)
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*Severe chronic obstructive pulmonary disease (COPD)
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*Central sleep apnea (CSA)
Indications:
 *Obstructive sleep apnea (OSA)
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**Arterial Blood Gas (ABG) PaCO2 (+/=) 45 mm Hg,
while awake on normal FIO2
**Spo2 (-/=) 88% for at least five consecutive minutes
on normal FIO2
** Mean Arterial Pressure (MAP) greater than 60cm
H2O or FVC greater than 50% of predicted
(progressive neuromuscular disease only)
(www.healthlink.com)
Hazards:
The BIPAP is intended to be used with special masks
or connectors that have exhalation ports to allow
continuous flow of air out of the mask. When the
device is turned on and functioning properly, new
airs from the device flushes the exhaled air out
through the mask exhalation port. However, when
the device is not operating, enough fresh air will
not be provided through the mask, and exhaled
air may be re-breathed. Re-breathing of exhaled
air for longer than several minutes can in some
circumstances lead to suffocation.
Contraindications:
 The BIPAP should not be used if you have severe
respiratory failure without a spontaneous respiratory
drive. If any of the following conditions apply to you,
consult your physician before using the device.
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Inability to maintain a patent airway or adequately
clear secretions in compromised person
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At risk for aspiration of gastric contents
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Diagnosed with acute sinusitis or otitis media
Contraindications:
 Allergy or hypersensitivity to the mask materials
where the risk from allergic reaction outweighs
the benefit of ventilator assistance
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Epitasis, causing pulmonary aspiration of blood
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Hypotension in compromised person
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Acute Severe Asthma-Asthma is a common disease that results in
reversible airway obstruction that could lead to air trapping.
Acute sinusitis- severe, sudden onset inflammation of one or
more para-nasal sinuses
Acute Respiratory Distress Syndrome (ARDS)- is a severe lung
disease caused by a variety of direct and indirect issues. It is
characterized by inflammation of the lung parenchyma leading to
impaired gas exchange with concomitant systemic release of
inflammatory mediators causing inflammation, hypoxemia and
frequently resulting in multiple organ failure. This condition is
often fatal, usually requiring mechanical ventilation and
admission to an intensive care unit. A less severe form is called
acute lung injury (ALI).
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Arterial Blood Gas (ABG) is a blood test that is primarily
performed using blood from an artery. The test is used to
determine the pH of the blood, partial pressure of carbon dioxide
and oxygen, and the bicarbonate level.
Aspiration- the act of inhaling, especially in the reference to the
pathological aspiration of vomitus or material foreign to the
respiratory tract
CO2 retention is a pathophysiological process in which too little
carbon dioxide removed from the blood by the lungs.
Central Sleep Apnea- during sleep the brain temporarily stops
sending signals to the muscles that control breathing. Central
sleep apnea often occurs in people who are seriously ill. For
example, it can develop in persons who have life-threatening
problems with the brainstem.
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Chronic obstructive pulmonary disease
(COPD) is a disease of the lungs in which the
airways become narrowed. This leads to a
limitation of the flow of air to and from the
lungs causing shortness of breath. In contrast to
asthma, the limitation of airflow is poorly
reversible and usually gets progressively worse
over time. This is also associated with air
trapping.
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Congestive Heart failure is the inability of the cardiovascular
system to perfuse the body tissue. This may be due to
cardiomyopathy, MI, or increased vascular resistance, excessive
fluid or interference by increased thoracic pressure.
Conjunctivitis- inflammation of the eye
Diaphragm- is a sheet of muscle extending across the bottom of
the ribcage. The diaphragm separates the thoracic cavity from the
abdominal cavity and performs an important function in
respiration
Endotracheal intubation- placement of a tube through the nose
or mouth through the larynx, vocal cords, and into trachea.
Epitaxis- bleeding from the nose
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Exhalation port- is the area that the patient exhales through
Expiratory-pertaining to the expiration of air from the lungs.
FiO2, in the field of medicine is the fraction of inspired oxygen in a
gas mixture. The FiO2is expressed as a number from 0 (0%) to 1
(100%). The FiO2 of normal room air is0.21 (21%).
Gastric Distension Aerophagia- is a condition that occurs when a
person swallows too much air, which goes to the stomach causing
abdominal bloating and frequent belching and may cause pain.
Guillain Barre-is an acute inflammatory demyelinating
polyneuropathy (AIDP), an autoimmune disease affecting the
peripheral nervous system, usually triggered by an acute
infectious process resulting in paralysis of the ventilatory muscles
Hypersensitivity- of or pertaining to a tendency of the immune
system to exhibit an excessive or exaggerated response against
environmental antigens that are not normally harmful
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Hypotension- an abnormal condition in which the blood pressure
is not adequate for normal perfusion and oxygenation of the
tissues
Inspired-the act of drawing air into the lungs in order to exchange
oxygen for carbon dioxide, the end product of tissue metabolism.
Mean Arterial Pressure(MAP) a national average blood pressure
in an individual. It is defined as the average arterial pressure
during a single cardiac cycle
Muscle weakness (or "lack of strength") is a direct term for the
inability to exert force with one's muscles to the degree that would
be expected given the individual's general physical fitness. A test
of strength is often used during a diagnosis of a muscular disorder
before the etiology can be identified
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Muscular dystrophy (MD) refers to a group of genetic,
hereditary muscle diseases that cause progressive
muscle weakness. Muscular dystrophies are
characterized by progressive skeletal muscle weakness,
defects in muscle proteins, and the death of muscle
cells and tissue.
Obstructive Sleep Apnea (OSA) is a common sleep
apnea caused by obstruction of the airway. It is
characterized by pauses in breathing during sleep..
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Otitis media- an inflammation in the middle ear (the
area behind the eardrum) that is usually associated
with the buildup of fluid which may or may not be
infected.
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Oxygen saturation (SO2), commonly
abbreviated as "sats", measures the percentage
of hemoglobin binding sites in the bloodstream
occupied by oxygen
PaCO, n partial pressure of carbon dioxide in
the blood. Critical in regulating breathing
levels and maintaining body pH
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Patent Airway- open or unblocked airway
Positive end-expiratory pressure (PEEP) is a term used
in mechanical ventilation to denote the amount of
pressure above atmospheric pressure present in the
airway at the end of the expiratory cycle. The
equivalent in a spontaneously breathing patient is
CPAP. PEEP is se t on the ventilator. On the BiPap
machine, this is called EPAP.
Pulmonary Edema- is swelling and/or fluid
accumulation in the lungs. It leads to impaired gas
exchange and may cause respiratory failure
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Sleep apnea (or sleep apnea in British English is a sleep
disorder characterized by pauses in breathing during sleep.
Each episode, called an apnea(Greek: ἄπνοια (ápnoia), from
α- (a-), privative, πνέειν (pnéein), to breathe), lasts more
than 10-20 second
Supine position-is a position of the body; lying down with
the face up.
Tidal Volume (Vt)-is the lung volume representing the
normal volume of air displaced between normal inhalation
and exhalation when extra effort is not applied.
Tracheotomy or tracheostomy- are surgical procedures on
the neck to open a direct airway through an incision in the
trachea (the windpipe).
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Subjects were gathered from Lone Star
Community College Kingwood
We had informed consent forms signed
and witnessed.
Test subjects were given detailed written
instruction
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universal circuit 1,000 series
small and medium nasal mask with strap
bacterial filter 22mm OD with 15 mm ID
hand held pulse ox by Tuff Sat
Bi-PAP ST-D model # 332003
Manufacturer Respironics Huntsville,
Pennsylvania
There is no calibration for the Bi-PAP ST-D
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Gathered equipment and made sure that we had 12 test
subjects... we explained the procedure to them and had
them sign the consent form...
then we accessed each test subjects heart rate, respiratory
rate, and SAT before the procedure and during
Next we turned on the Bi-PAP and attached the nasal mask
to the test subject with the Velcro straps making sure that a
minimal leak of < 20 was present.
Next, we set the IPAP 8 and EPAP 5, and the test subject
were on room air. We placed the pulse ox on the test
subjects and monitored the heart rate, respiratory rate, and
SAT during the whole procedure to make sure the test
subjects were stable
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We started with the test subjects in the supine
position... we then observed the test subjects
tidal volumes and wrote down the better of
three for each subject.
We then changed the test subjects’ position to
the semi-fowler and observed the tidal
volumes as we did in step 3.
Last we put the test subjects in the high fowler
position and observed the tidal volumes just
like we did in steps 3 and 4.
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Upon completion of the procedure we
compared the test subjects tidal volumes
from each position to see if the subject
position did affect the return tidal volume.
1000
900
800
700
600
SUPINE VT
500
SEMIFOWLER VT
HIGH FOWLER VT
400
300
200
100
0
C1
C2
C3
C4
C5
C6
C7
C8
C9
C10
C11
C12
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Previous slide had all original data from the 3
positions that the subjects were in and the Tidal
Volumes they produced.
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Average Vt in males in supine position= 740
Average Vt in males in semi-fowler position= 687
Average Vt in males in high-fowler position=723
Average Vt in females in supine position= 662
Average Vt in females in semi-fowler position=697
Average Vt in females in high-fowler position=674
Caucasian
C1
C2
African
American
Asian
X
X
C3
X
C4
X
C5
X
C6
X
C7
X
C8
C9
X
X
C10
X
C11
X
C12
Hispanic
X
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Average Vt for a Caucasian in supine
position= 686
Average Vt for a Caucasian in semi-fowler
position=681
Average Vt for a Caucasian in high-fowler
position= 670
Average Vt for an African American in supine
position= 652
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Average Vt for an African American in
semi-fowler position =675
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Average Vt for an African American in
high-fowler position=650
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Average Vt for an Asian in supine
position 777
Average Vt for an Asian in semi-fowler
position=833
Average Vt for an Asian in high-fowler
position=820
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Average Vt for a Hispanic in supine
position=558
Average Vt for a Hispanic in semi-fowler
position=561
Average Vt for a Hispanic in high-fowler
position=577
Left Handed
Right Handed
C1
X
C2
X
C3
X
C4
X
C5
X
C6
X
C7
X
C8
X
C9
X
C10
X
C11
X
C12
X
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Average Vt for a right handed person in supine
position=679
Average Vt for a right handed person in
semi-fowler position=680
Average Vt for a right handed person in
high-fowler position=744
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Average Vt for a left handed person in supine
position=709
Average Vt for a left handed person in
semi-fowler position=853
Average Vt for a left handed person in
high-fowler position=824
% change in Supine VS
High fowler
% change in Semifowler % change in Supine VS
Vs
High fowler
-2.649
8.89423
6.00961
0.199601
10.8407
10.8407
-0.53475
-2.77296
-3.29289
-8.16326
1.47928
-6.80473
-7.28862
-0.72358
-7.95947
-0.15723
-6.47058
-6.61764
-5.7377
8.51334
3.47043
-0.11299
4.77001
3.05429
17.58793
-10.8623
4.81522
-16.8816
1.33495
-13.9563
3.81303
16.50853
3.43137
-7.65472
16.50854
7.59013
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Range supine 441-936
Range semifowler 453-885
Range highfowler 416-893
Median in supine 635.5
Median in semifowler 686
Median in highfowler 685.5
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Based on our finding there was not a
significant change in tidal volume based on
positional changes.
Only two out of twelve subjects had a percent
change greater than fifteen percent.
Limitations:
 Time and money
 Limited number of test subjects
 Study was only done on healthy people
 Nasal mask only not full face mask
New biological questions: It would be nice to
see this test done on:
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Patients that have sleep apnea (OSA and CSA)
Patients with restrictive disorders
Patients with COPD
Sleeping test subjects
The differences between the test subjects’
tidal volumes were not significant in the
positional changes, therefore we conclude
that moving the patients’ positions had no
benefit on the return tidal volume of
healthy awake individuals.
(Becker, et al., 1993, pp. 184-188)
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