HWN Suggests

Selling Ice Cream in the Desert

It's clear from both evidence and experience that NIV (aka NIPPV, CPAP, BiPAP) is very helpful for most acutely sick, dyspneic patients on a range of outcomes: symptom improvement, oxygenation, potential avoidable intubation, or preoxygenation for ETI.

However, many patients are initially resistant to NIV for a variety of reasons including:

• hypoxic delirium
• delirium from the disease process itself
• hypercarbia
• sensation of drowning, i.e. the worst sensation in the world
• While some may question why patients don't always instantly welcome lifesaving therapy with open armed-compliance, it's easy to understand why someone you've never…

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Featured

  Mastering the dark arts of BiPAP & HFNC

Skillful use of BiPAP and high-flow nasal cannula (HFNC) can avoid intubation and improve outcomes. However, there isn't comprehensive evidence about the nitty-gritty details of these techniques. In this post I will use my opinions to fill some gaps in the evidence (1). Noninvasive respiratory support remains more of an art than a science, perhaps a dark art at that.

 Bi-level Ventilation: Who Needs it and Who Doesn’t? Pearls and Pitfalls

Endotracheal intubation is a life-saving intervention when applied skillfully, but its attendant risks are well described. Staving off intubation has been shown to decrease complications such as hypotension, arrhythmias, death, and nosocomial infections. Intubation also places patients at an increased need for sedation and invasive procedures. Noninvasive ventilation has become commonplace in the ED to treat respiratory failure and prevent intubation.

Articles of Interest

Non-Invasive Positive Pressure Ventilation in the ED

Due to the multitude of indications, it is important for emergency physicians to understand both the ventilator settings of NIPPV devices and the types of respiratory failure they address.

Setting Up Non-Invasive Ventilation

Allan Guiney, MD and Salil Bhandari, MD review the steps in setting up a Bilevel Positive Airway Pressure machine.

BiPAP and a Prayer

I’d like to think it was the nitro/BiPAP/Lasix and quick action by our team that made the difference. But maybe when the chips are down, an exorcism is just what you need.

Evidence-Based EMS: Out-of-Hospital BiPAP vs. CPAP

After looking at the evidence of BiPAP against CPAP, the only advantage BiPAP appears to provide is a decreased time to resolution of respiratory symptoms, vital signs and improvement of laboratory values. However, keep in mind that this difference doesn’t occur until late in the treatment course. While this shouldn’t affect most EMS systems with short transport times, some rural EMS systems may take the long-term effects of BiPAP into consideration given their longer transport times. Otherwise, current evidence demonstrates minimal benefit to BiPAP over CPAP.

Pediatric BIPAP

Deployment of CPAP and BIPAP in EMS has evolved over the last decade and is arguably first line intervention for acute respiratory distress for multiple adult populations. Despite these advances, we have left children behind for no reason.

Positively Useful: A Brief ED Guide to NIPPV

When utilized optimally, NIPPV improves oxygenation, work of breathing, respiratory mechanics, and cardiac function. It should be considered for any dyspneic patient presenting to the ED assuming no contraindications exist. Among the most supported indications for NIPPV are ACPE and COPD.

Preventing intubation in acute respiratory failure: Use of CPAP and BiPAP

However, the increasing use of noninvasive ventilatory support (NIVS) has further decreased the need for endotracheal intubation in this patient population. Indeed, the use of NIVS in the Emergency Department is probably one of the most significant advances in the care of patients with acute respiratory failure in recent years.

Resources

FP Notebook

Only BiPap (not CPAP) is effective however in hypercarbic Acute Respiratory Failure (Ventilatory failure).

REBEL EM

Respiratory Failure – The Rule of 2s (This is a simplified algorithm as there can be mixed respiratory failure).