Definition
A bi-level positive airway pressure (BIPAP) is a means of non-invasive ventilator support that uses either flow or time to cycle between inspiratory positive airway pressure (IPAP) and expiratory positive airway pressure (EPAP), supported with supplemental oxygen and a backup respiratory rate.
Indications
- Chronic obstructive pulmonary disease exacerbation.
- Pulmonary edema/fluid overload.
- Respiratory support postextubation.
- Respiratory failure with respiratory rate >45/minute, PaCO2,>45 mm Hg with pH≤7.35, and PaO2, /FiO2, <200 mm Hg.
Contraindications
- Severe hypoxemia (PaO2,/FiO2, <75).
- Severe acidemia.
- Multiorgan failure or slowly reversible disease (in short term).
- Upper airway obstruction.
- Anatomic abnormalities that interfere with gas delivery.
- Respiratory arrest, apnoea.
- Cardiac arrest and hemodynamic or cardiac instability.
- Uncooperative patient.
- Encephalopathy with inability to protect airways and a high-risk of aspiration.
- Increased risk of aspiration: copious secretions, vomiting, or severe gastrointestinal bleeding.
- Recent airway or gastrointestinal surgery.
- Inability to fit mask
Nursing care of patients on BIPAP
Procedure
| Nursing action | Rationale | |
| 1. | Assess for indications/ contraindication | Determines the need for keeping the patient on NIV (Non –invasive ventilation). |
| 2. | Obtain order from physician. | |
| 3. | Assemble equipment (BIPAP machine fitting mask, protective gel, oxygen source). | Provides an organized approach during the procedure and ensures patient safety. |
| 4. | Explain procedure to patient and family. | Proper explanation of the procedure helps to ensure patients co-operation and effectiveness of the treatment. |
| 5. | Respiratory therapist or nurse to ensure ordered setting in the machine. | |
| 6. | Ensure proper mask fit and gel protectors for preventing skin breakdown. | A poor fitting mask leaks, compromises ventilation and patient comfort and can result in skin damage. |
| 7. | Monitor patient for and document hourly: ventilator pressures row, level of consciousness, breath rate, pattern, and respiratory effort, heart rate, use of accessory muscles, oxygen requirement, continuous pulse oximetry and ECG monitoring, compliance/comfort with therapy, patient respiratory synchronization with bi-level ventilation. | Monitoring of the patient ensures the efficacy of ventilation and provides information on progression of the patient’s condition. |
| 8. | Ensure blood gas monitoring and End Tidal oxygen monitoring as per protocol or per order. | Helps to identify the clinical progression of the patient and need for discontinuation of NIV. |
| 9. | Ensure oral care every 2 hours to prevent crusting of secretions. | |
| 10. | Monitor pressure areas for skin breakdown. | Help identify pressure ulcers at the earliest. |
| 11. | Consider alternate methods of nutrition as oral nutrition may not be tolerated and nasogastric tube feeding may result in distention and aspiration of feeds. | Ensures that nutritional requirements are met. |
| 12. | Educate and provide support for patient and family. | Allays anxiety and promotes cooperation. |
Complications
Clinical
- Pneumothorax
- Decreased cardiac output
- Gastric distension
- Mucus plugging
- Nasal congestion
- Aspiration
- Pressure areas from mask, tubing, and strapping
Mechanical
- Inadequate ventilation (i.e.: hypoxemia, hypercapnia)
- Over ventilation (i.e., hypocapnia)
- Mechanical failure of ventilation and humidifier
- Non ‘synchronization’ with device
- Circuit leak and damage
Problems Related to BIPAP Ventilation
- Discomfort due to tightly fitting face mask.
- Mild abdominal bloating.
- Eye irritation.
- Sinus pain or congestion.
Safety Measures
- Change/clean circuit weekly or PRN.
- Clean mask daily or PRN.
- Refresh water in humidifier daily using sterile distilled water.
- Wash hands before and after taking care of patients.
Follow patient safety alerts, such as use of CO2, exhalation port on interface, presence of anti-asphyxiation valve on full and total face masks, and patient’s ability to self-ventilate in event of mechanical failure.
BIPAP Modes
In BIPAP, we give two levels of pressure, IPAP and EPAP. They are set after assessing the patient’s condition and type of disease. IPAP is basically the positive airway pressure that we give in inspiration and EPAP is expiratory positive airway pressure that prevents our alveoli from collapsing and keep them open.
Spontaneous mode is a mode where all the breaths of the patient are triggered and cycled. Machine delivers preset pressure during inspiration and expiration. No automatically delivered breath is inhaled. Patients initiate all the breaths and machine respond to inspiration and expiration triggers.
Spontaneous timed mode is a mode in which breaths are both patient-triggered, and machine triggered, as well as patient cycled, and machine cycled. We set backup breaths and the time interval. If patient do not initiate the breath during the set time, then machine automatically delivers the breath.
Timed mode is a mode in which the machine does not rely on patient breath triggering effort. All the breaths are automatically delivered and set.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
- Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/
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