what is standard criteria for instituting mechanical ventilation
- apnea or absence of breathing
- acute ventilatory failure
- impending ventilatory failure
- refractory hypoxemic respiratory failure with increased WOB or innefective breathing pattern
what are indications for NPPV in adults
- respiratory rate >25 breaths per minute
- moderate to severe acidosis: pH 7.25 - 7.30; PaCO2 45 mmHg - 60 mmHg
- moderate to severe dyspnea with use of accessory muscles and paradoxical breathing pattern
what are absolute contraindications of NPPV in adults
- respiratory arrest
- cardiac arrest
- cardiovascular instability
- nonrespiratory organ failure
- patent tracheoesophageal fistula
- inability to protect the airway or high risk for aspiration
- uncooperative patient
- facial or head surgery or trauma
what are relative contraindications of NPPV in adults
- copious or viscous secretions
- fixed nasopharyngeal abnormalities
- extreme obesity
what are circumstances in which NPPV should change to invasive ventilation
- respiratory arrest
- respiratory rate > 35 breaths/minute
- severe dyspnea with use of accessory muscles and possibly paradoxical breathing
- life threatening PaO2 < 40 mmHg or PaO2/FiO2 < 200
- severe acidosis (pH < 7.25) and hypercapnia (PaCO2 > 60 mmHg)
- hypersomnolence, impaired mental status
- cardiovascular complications (hypotension, shock, heart failure)
- failure of NPPV
- other circumstances (metabolic abnormalities, sepsis, pneumonia, pulmonary embolism, barotrauma, massive pleural effusion)
what is the rule for low pressure alarms
minus 5-10 below PIP
what is the rule for high pressure alarms
plus 10 above PIP
what is the rule for high rate alarms
plus 10 above spontaneous rate
what is the rule for low rate alarms
between low rate and spontaneous rate
what is the rule for high tidal volume alarms
plus 20% above spontaneous tidal volume
what is the rule for low tidal volume alarms
minus 20% below spontaneous tidal volume
what is the rule for low minute ventilation alarms
minus 20% of spontaneous minute ventilation
rise is used on what type patient
acute or chronic patient for comfort
ramp is used for what type patient
chronic but stable patients
if a patient complains of nausea while wearing NPPV what is the short term fix
take the mask off and allow patient to expel gas while assessing for gastric inflation
if a patient complains of nausea what are long term fixes
- lower pressures to lowest tolerated
- try a different interface
- ask nurse to place NG tube to help expel air
what do you do if a patient is apneic on NPPV
- do ABC assessment
- if no pulse start CPR
- long term look to intubate
what are the ways to tell if a patient is apneic on NPPV
- timed breaths indicated by machine
- orange color waveform graphic
- patient trigger percent is low
- Ti/TOT is low
what do you do if there is mask discomfort
check mask for correct size and fit
what do you do if there is excessive leaks around mask
minimize headgear tension by undoing and readjusting with equal offloading pressure
what do you do if there are pressure sores
- use spacers or switch mask styles
2. use wound-care dressing over nasal bridge
what do you do if there is nasal/oral dryness or nasal congestion
- add or increase humidification
- irrigate nasal passages with saline
- apply topical decongestants
- use chin-strap to keep the mouth closed
- change to full-face mask
what do you do if there is mouthpiece/lip seal leakage
- use nose clips
2. use custom-made oral appliances
what do you do if there is aerophagia, gastric distention
- use lowest effective pressures for adequate tidal volume
2. use simethicone agents
