Mod 7 Non-invasive Flashcards
What can you use to guide CPAP treatments?
CxR (pre and post) mostly as needed.
- To check for overdistension
How often do you pull a CPAP mask off to change the interface?
- why?
Every 6 hours.
- swap to prongs to not cause breakdown at the surface level of skin/cause pressure sores.
What are indications for CPAP/SiPAP (5)
- Respiratory distress (retractions, nasal flaring, grunting)
- CxR findings of decreased lung volumes and/or pulmonary infiltrates
- Post-extubation mode for all infants<33 weeks corrected gestational age
- Apnea of Prematurity
- Pulmonary edema (CHF or PDA w/(L->R) shunt)
What are the primary physiological effects of CPAP? (6)
- Increases FRC and Vt
- Decreases intrapulmonary shunt
- Increases pulmonary compliance
- Decreases airway resistance
- Improved V/Q ratio
- Decreases WOB and reduces alveolar dead space
How does CPAP affect the upper airways?
CPAP stabilizes the chest wall and upper airways.
- Prevents obstructive apnea
How does CPAP affect the lower airways?
Decreases WOB and reduces alveolar dead space (stents alveoli open = more surface area for gas exchange)
- Better type 2 pneunocyte function and even recycling of surfactant (aids recovery from RDS)
- Decreases cellular indicators of lung injury
What is a absolute requirement for CPAP
Patient needs to have a intact ventilator drive and the ability to move air
What patients can move on from mechanical ventilation to CPAP?
- PaCO2 >60
- pH <7.25
What are contraindications for CPAP?
- Need for intubation/mech vent.
- upper airway abnormalities (i.e choanal atresia)
- Hemodynamically unstable (could arrest)
- vent. failure
How can CPAP be performed/delivered?
- Mechanical vents
- Bubble CPAP devices
- SiPAP (is CPAP via BiPAP mode)
- High Flow Nasal Prongs (needs a blender to control FiO2)
Why are High Flow Nasal Prongs not the go to for delivering CPAP?
High Flow Nasal Prongs don’t really provide CPAP (to its full extent) because they can’t occlude the nose enough.
- Pressure is highly variable
- Prongs are < 50% of nares diameter
What should your initial CPAP levels be?
4-6, but you shouldn’t wean to 4 if possible (don’t get much out of it)
Bubble CPAP?
what is SiPAP?
A very effective method of delivering CPAP.
- is its own specific device
what settings should you initially set and make sure are running when operating a High Flow Nasal Cannula?
- Head and humidified
- Flow up to 8 LPM
- FiO2 adjusted w/blender
What should you recognize as a sign that a kid doesn’t need CPAP anymore?
Term kids fight the machine (pull the mask/tubes)
- They might be better left on prongs
- premies are usually fine
- Can only tolerate CPAP in intervals (sometimes 1hr at a time)
What are things to check if you suspect CPAP failure?
- Baby is not fighting CPAP interface
- Nasal prongs are correct size
- Adequate humidity w/o condensation in circuit
- Adequate pressure and FiO2 delivered (check neck position, clear nostrils and airways)
- Surfactant has been admin’d in cases of RDS
What are markers of CPAP failure?
- Increased WOB, nasal flaring and retractions
- Decreasing pH <7.25 and PaCO2 > 60
- Increasing FiO2 needs w/PaO2 < 50-60
- Nasal CPAP exceeding 8-10 cmH2O
- Frequent apnea w/cyanosis and bradycardias with no reaction to caffeine therapy.
What are indicators of effective CPAP (stabilization)?
- Comfortable infant
- Reduced RR
- Minimal or no chest retractions
- Reduction in severity and frequency of apneic episodes
- Appropriate blood gas (need to check)
How is SiPAP (Synchronized Intermittent Positive Airway Pressure) different from CPAP?
- Hint synchronization
In SiPAP the delivery of positive pressure is synchronized with the patient’s respiratory efforts. (pressure variability)
- AKA the device senses the patient’s spontaneous breaths and delivers pressure support in sync with their breathing pattern.
- In contrast, CPAP provides continuous, unchanging levels of pressure
- More comfortable than CPAP, allows the Pt to spontaneously breath
- It is suitable for patients who require synchronized support and are not in a condition to initiate breaths entirely on their own.
How does BiPAP ventilation deliver PEEP and differ from CPAP
Bipap delivers 2 pressures (IPAP and EPAP)
- IPAP is set at a higher pressure delivered during inhalation to assist with oxygenation and promote effective ventilation
- EPAP is set at a lower pressure maintained during exhalation to help keep the airways open.
- used to reduce the work of breathing, improve oxygenation, and support patients in respiratory distress
How does Biphasic ventilation deliver PEEP and differ from CPAP
In your initial assessment:
- how would you know if a Pt is ready for weaning from CPAP?
- how would you begin weaning?
- What does the timeline of weaning look like before d/c?
- Pt has Low WOB and low Fio2 at current support.
- You wean by leaving CPAP at the same level until able to maintain target SpO2 w/FiO2 <0.25
- Lower CPAP level by 1, pay attention to SpO2 for the first 6-24hrs (key is to see stabilizing FiO2 w/less support and less apneic periods)
- if there is no significant apnea w/SpO2 >85% after 2-days w/FiO2 = 0.21. d/c
- If d/c’d start NP @0.5-1 lpm
What should you do after discontinuing CPAP?
Start nasal prongs at 0.5-1.0 lpm
What should your initial SiPAP settings be? (3)
- RR 20
- Pressure at 9/6 (always want a delta of at least 3)
- Ti 1 second
What are your 2 Biphasic modes?
- BP-NCPAP (set IPAP and EPAP)
- NCPAP (set just CPAP)
In Biphasic CPAP, when would you increase your Ti to 2 seconds?
When the Patient has increased FiO2 > 0.30
In Biphasic CPAP, when would you increase your Ti to 3 seconds?
When the Pt further deteriorates from FiO2 >0.30
- Decrease R to 15
- Increase Ti to 3 seconds
What are conditions for weaning Biphasic?
- What should you do when d/c’d?
- SpO2 >85% for 80% of the time, mild WOB, and no significant apnea events.
- Initiate CPAP/SiPAP after d/c
What guidelines should you follow with NPPV for pediatrics?
Similar to adults.
- Focus on RR and WOB
- Evaluate w/clinical assessments and ABGS
What is the primary goal of NPPV? (4)
Decrease WOB and improve respiratory gas exchange.
- Decrease WOB
- Improve respiratory gas exchange
- Increased FRC
- Increased patency of the oral-pharyngeal airway and decreased intrinsic auto peep
How do you know if you have effectively decreased WOB?
- how is it manifested?
- Decreased RR
- Decreased retractions
- Decreased use of accessory muscles of breathing
How do you know if you have effectively improved respiratory gas exchange?
- how is it manifested?
- Decreased arterial PaCO2
- Increased arterial PaO2
- Increased arterial pH
Benefits of Biphasic
Avoiding derecruitment, maintains optimal volume and FRC.
Initial Biphasic CPAP settings?
RR 20
- Pressure 9/6 (delta 3)
- Ti 1 second
Biphasic: Fio2 requirements increasing?
Increase MAP by Ti
