Device | Bilevel positive pressure device |
Portable home ventilator | |
Location | Chronic ventilator or step-down unit versus intensive care unit |
Monitors | Trend pulse oximetry (SpO2) Heart rate Respiratory rate |
Initial setup | Select/adjust nasal mask |
Connect patient to bilevel positive pressure device (BPAP) in spontaneous mode | |
Start IPAP = 6; EPAP = 2 cmH2O | |
Supplemental oxygen at 0-3 LPM for SpO2 less than 89 percent | |
Observe | Tolerance (log patient's complaints) |
Dyspnea (Borg scale) | |
Synchrony (rib cage/abdominal excursion with IPAP onset) | |
SpO2 | |
Vital signs | |
Arterial blood gas in the morning | |
Nasal mask titration | Increase IPAP by 2 cmH2O as tolerated up to a maximum of 20 cmH2O |
Increase EPAP to 4 to 6 cmH2O as needed to improve SpO2 or decrease work of breathing in COPD patients | |
FiO2 increased only after ventilation improved. Goal is to achieve SpO2 90 to 93 percent | |
Switch to spontaneous/timed (S/T) mode at 12 breaths/min if indicated | |
Face mask titration | Patients failing nasal mask will proceed to full face mask and above titration will be repeated |
Patients failing full face mask and BPAP will proceed to volume ventilator (See Failure of nocturnal noninvasive ventilatory support below) | |
Volume ventilator | Full face mask |
Mode - assist control | |
Flow - start 60 LPM | |
Rate - set 2 to 4 bpm below patient spontaneous rate | |
Volume - as tolerated but target minute ventilation >10 LPM | |
FiO2 increased only after ventilation improved. Goal is to achieve SpO2 90 to 93 percent | |
Failure of nocturnal noninvasive ventilatory support | Patient refuses to accept either the nasal or face mask (anytime during the trial) |
Unacceptable deterioration in mental status (anytime) | |
Intolerable dyspnea at any time or Borg scale >15 with no improvement | |
Consider tracheostomy or other more acute treatment |
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