HHS CPO HFNC and NIPPV

HFNC Benefits

• Precise FiO₂ (21%-100%) to improve oxygenation

• High flow rates (up to 70 LPM) → alleviate respiratory distress

• Optimal heat (37 C) and humidity improves pt comfort/compliance and enhances mucous clearance

HFNC Indications

• High O₂ requirements

• Mild to moderate respiratory distress

• Bridge between conventional oxygen therapy and non-invaisive ventilation

• Pt uncomfortable/non-compliant with oxygen therapy with mask (associated with a drop in SpO₂ below acceptable limits)

HFNC Contraindications

• aLOC and/or apneas

• Acute respiratory failure (inc PaCO₂, dec pH)

• Untreated pneumothorax or pneumomedianstinum

• Postop abdo sx

• Mucosal edema

• Airway anomalies

• Deviated septum

Settings (HFNC)

1. Temperature

2. Flow

3. FiO₂

Temperature Settings (HFNC)

• 31

• 34

• 37

Flow Settings (HFNC)

• Rate of gas flow through cannula

• Set and titrated based on WOB

• Adults between 30-70 L/min

FiO₂ Settings (HFNC)

• % of O₂ delivered to pt

• Set and titrated based on SpO₂ and PaO₂

• 0.21-1.0 (100%)

Oxygen Titration by Nursing

• CAN ONLY TITRATE FiO₂!!!

• Maximum change of 10%

• Must contact RT immediately

• Adjust using flow meter

HFNC Assessment Q4 (RN/RT)

• SpO₂

• HR

• RR

• WOB

• Air entry via auscultation

• Need for suctioning

• Skin integrity

Stable HFNC

FiO₂ less than 50%, flow rate stabilized or weaning (ward)

Unstable HFNC

FiO₂ 50% or greater, flow rate escalating (stepdown or critical care)

Airvo Trach

Heated humidity to trach pt, rate 20-30 L/min (not considered HF)

NIPPV Definition

Assists ventilation by delivering pressurized air. Senses pt respiratory effort by monitoring airflow within the circuit

Goals of NIPPV

• Decrease WOB

• Improve oxygenation

• Reduce/avoid intubations

• Promote lung recruitment

• Reduce amount of sedation used

• Reduced resp muscle fatigue

• Decrease incidence of ventilator associated pneumonia

• Improve pt mobiliation, communication

• Decreased length of ICU stay

• Reduce hospital mortality

NIPPV Indications

• Ventilation failure (elevated or rising PaCO₂, moderate-severe acidosis)

• Oxygenation failure

• Respiratory muscle weakness/fatigue (neuromusclar disorders)

• Acute pulmonary edema

• OSA

• Chest wall deformitites

• Physician ordered scope of treatment (POST)

NIPPV Absolute Contraindications

• Respiratory arrest with no spontaneous respiratory effort

• Cardiac arrest

• Patient refusal

• Upper airway obstruction

• High risk for aspiration

• Inability to protect airway (decreased LOC)

• Acute GI bleed

NIPPV Relative Contraindications

• Copious secretions

• Hemodynamic instability

• Emphysema

• Sinus/ear infection

• Noncompliant pt

NIPPV Possible Complications

• Skin breakdown

• Decreased CO

• Hypotension

• Arrhythmias

• Gastric distension

• N/V

• Eye irritation

• Tension pneumo

PEEP (Positive End Expiratory Pressure)

Positive pressure maintained in airways at the end of expiration. Used to splint open airways, improve gas exchange, prevent alveolar collapse

• Physiological PEEP is 3-5 cmH₂O

CPAP

Single pressure level, pt breathes spontaneously from elevated baseline pressure

• Set: PEEP or EPAP + FiO₂

CPAP Indications

Oxygenation (PaO₂) problems

• OSA

• Atelectasis

• Ischemic heart disease

PS/IPAP

IPAP → Inspiratory positive airway pressure (set above 0)

PS → Pressure support (usually set above PEEP)

• Positive pressure delivered and maintained during inspiration

• Supports pt effort

Max pressure = PS + PEEP

BiPAP

Two pressure levels

• Set: PEEP or EPAP + IPAP or PS + FiO₂

IPAP vs EPAP

IPAP always set higher than EPAP - Difference determines volume of breath

• Larger pressure difference → larger volume

BiPAP Backup

PEEP/EPAP + IPAP/PS + RR + FiO₂

• If not resp effort detected, will be used to ventilate until intubation

BiPAP Indications

Ventilation (PaCO₂) and/or oxygenation (PaO₂) problems

• Pulmonary edema

• COPD

• Obesity hypoventilation syndrome

• Severe OSA

• Central sleep apnea

• Neuromuscular disorders

Type 1 NIPPV Patients

Acute NIV need. Unstable, requiring marked clinical improvement (Critical care, stepdown)

• Must be awake, oriented, capable of calling for help

Type 2 NIPPV Patients

Require NIV, short term discontinuation does not pose life threatening risk (Location determined by MD/RT/RN)

Type 3 NIPPV Patients

Non-acite, stable. Established NIV treatment, including nocturnal CPAP (Wards)