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					          HEALTH SERVICE
            EXECUTIVE
              SOUTH




     POLICY ON NON-INVASIVE
        POSITIVE PRESSURE
       VENTILATION (NIPPV)
    FOR PATIENTS WITH TYPE 2
      RESPIRATORY FAILURE




                                  Index No:           Resp 2
POLICY ON NON-INVASIVE POSITIVE   Date of Approval:
PRESSURE VENTILATION FOR TYPE 2   Revision Date:      27/06/2010
     RESPIRATORY FAILURE          Revision No:        2
                                  Page No:            Page 1 of 22
                                                    Index No:            Resp 2
 POLICY ON NON-INVASIVE POSITIVE                    Date of Approval:
 PRESSURE VENTILATION FOR TYPE 2                    Revision Date:       27/06/2010
      RESPIRATORY FAILURE                           Revision No:         2
                                                    Page No:             Page 2 of 22


                                                    SIGNATURE              DATE

Developed by:         Samantha Conroy               _____________          _________
                      CNS Respiratory

                      Emma Smyth                    _____________          _________
                      Physiotherapy Manager

Consultation with:    Dr Colm Quigley               _____________          _________
                      Consultant Physician

                      Emer Ward                     _____________          _________
                      CNS Infection Control

Approved by:          Mr Bernard Finnegan           _____________          _________
                      Director of Nursing

                      Norma Sheehan                _____________           _________
                      A/Nurse Manager
                      Medical Clinical Directorate

                      Eilis Redmond                _____________           _________
                      Practice Development Facilitator




Disclaimer:
Each situation must be judged on its own merits and it is unreasonable for readers to
follow instructions in the guideline, policy or protocol without proper assessment of
individual circumstances. The information contained within this guideline, policy or
protocol is the most accurate and up to date at time of approval.
                                                Index No:           Resp 2
 POLICY ON NON-INVASIVE POSITIVE                Date of Approval:
 PRESSURE VENTILATION FOR TYPE 2                Revision Date:      27/06/2010
      RESPIRATORY FAILURE                       Revision No:        2
                                                Page No:            Page 3 of 22


                                 CONTENTS
1. 0 Purpose                                                                 5
2. 0 Policy                                                                  5
3. 0 Applies to                                                              5
4.0 Definitions                                                              5
       4.1 Non Invasive positive Pressure Ventilation                        5
       4.2 Abbreviations                                                     6
5.0 Responsibilities                                                         6
       5.1 Responsibility of Medical Team                                    6
       5.2 Responsibility of CNS Respiratory                                 7
       5.3 Responsibility of Nursing Staff                                   7
       5.4 Responsibility of The Respiratory Physiotherapist                 8
       5.5 Responsibility of Physiotherapists                                8


6.0 Indications for Use                                                      9

7.0 Procedure                                                                10
      7.1 Inclusion Criteria                                                 10
      7.2 Exclusion Criteria                                                 10
      7.3 Relative Exclusion Criteria                                        10

8.0 Persons Authorised to Prescribe NIPPV                                    11
       8.1 Prior to prescribing NIPPV                                        11
       8.2 Prescribing NIPPV                                                 11

9.0 Persons Authorised to Set-Up, Initiate & Make Adjustments
    According to Prescription                                                12
       9.2 Persons Unauthorised to Set-Up, Initiate or Make Adjustments
           to NIPPV                                                          12

10.0 Clinical Areas Where NIPPV Is Used                                      12

11.0 Storage of Equipment                                                    12

12.0 Maintenance of Equipment                                                12

13.0 Preparing A Patient for NIPPV                                           13
       13.1 Psychological Support                                            13
       13.2 Preparation                                                      13

14.0 Initial Set-Up                                                          14

15.0 Promoting Patient Comfort                                               15
                                           Index No:           Resp 2
 POLICY ON NON-INVASIVE POSITIVE           Date of Approval:
 PRESSURE VENTILATION FOR TYPE 2           Revision Date:      27/06/2010
      RESPIRATORY FAILURE                  Revision No:        2
                                           Page No:            Page 4 of 22

16.0 Mask Fitting                                                       15

17.0 Adjustments Of NIPPV                                               17

18.0 Monitoring The Patient During NIPPV                                17

19.0 Weaning Off NIPPV                                                  18

20.0 Cleaning Equipment and Consumables                                 18

21.0 Implementation Plan                                                19

22.0 Resource Implications                                              19

23.0 Revision History                                                   19

24.0 Evaluation And Audit                                               19

25.0 Bibliography                                                       19

26.0 Appendices                                                         20
                                                    Index No:              Resp 2
 POLICY ON NON-INVASIVE POSITIVE                    Date of Approval:
 PRESSURE VENTILATION FOR TYPE 2                    Revision Date:         27/06/2010
      RESPIRATORY FAILURE                           Revision No:           2
                                                    Page No:               Page 5 of 22




1. 0 Purpose

      To outline the responsibilities of team members in relation to the management
       of patients with acute respiratory failure receiving non-invasive positive
       pressure ventilation within the determined unit.
      To provide guidelines on the setting up and administration of non-invasive
       positive pressure ventilation.
      To provide guidelines for the monitoring, surveillance and care of patients
       undergoing non-invasive ventilation.


2. 0 Policy

Wexford General Hospital supports the safe care of patients receiving non-invasive
positive pressure ventilation for certain categories of Acute (Type II) Respiratory
Failure.

3. 0 Applies to
                 Consultants
                 Registrars
                 Nurses who are caring for patients on NIPPV
                 Physiotherapists
                 CNS Respiratory

4.0 Definitions

   4.1 Non Invasive Positive Pressure Ventilation (NIPPV)
   Non-invasive positive pressure ventilation is the delivery of mechanically
   generated breathing support without the placement of an artificial airway.
   “Positive pressure” is air delivered into the lungs at a set airway pressure, bi-level
   positive airway pressure (Bipap) delivers an inspiratory positive airway pressure
   and an expiratory positive airway pressure and therefore supports a person’s
   normal breathing in order to:
    Decrease the work of breathing
    Increase minute ventilation
    Increases the level of oxygen in the blood
    NIPPV has a number of advantages over intubation in patients with acute
       respiratory failure. Airway defence mechanisms (gag, coughing), speech and
       swallowing function are left intact. Trauma to the larynx and trachea are
       avoided and patient comfort is improved.
                                                   Index No:           Resp 2
 POLICY ON NON-INVASIVE POSITIVE                   Date of Approval:
 PRESSURE VENTILATION FOR TYPE 2                   Revision Date:      27/06/2010
      RESPIRATORY FAILURE                          Revision No:        2
                                                   Page No:            Page 6 of 22

      Early use of NIPPV expedites recovery and reduces the number of patients
       requiring invasive ventilation and reduces in-hospital mortality. (Plant 2000)

       Complications of NIPPV

      Aspiration Pneumonia
      Hypotension
      Pneumothorax
      Respiratory arrest


   4.2 Abbreviations

      ARF – Acute respiratory failure
      ABG – Arterial blood gas
      BiPap – Bi-level intermittent positive airway pressure
      COPD – Chronic Obstructive Pulmonary Disease
      EPAP – Expiratory peak airway pressure
      Fi0² - Fraction of inspired oxygen
      FEV¹ - Forced expiratory volume in 1 second
      FVC – Forced vital capacity
      IPAP – Inspiratory peak airway pressure
      NIPPV – Non-invasive positive pressure ventilation
      Pa0² - Partial pressure of oxygen
      PaC0² - Partial pressure of carbon dioxide
      PEEP – Positive end expiratory pressure
      RPM – Respirations per minute
      Sa0² - Oxygen saturation level (pulse oximetry)
      S/T – Spontaneous timed mode


5.0 Responsibilities

       5.1 Responsibility of the Medical Team

              5.1.1    The Medical Team will decide if a patient requires NIPPV
              5.1.2    The Medical Team will order the initiation of NIPPV.
              5.1.3    The prescribing Doctor can set up NIPPV
              5.1.4    The prescribing doctor should remain with the patient for at
                       least half an hour following initial commencement of NIPPV.
              5.1.5    Evaluate the efficacy of the therapy and prescribe changes to
                       the machine settings or discontinuation.
              5.1.6    Re-evaluate the therapy at 1 hour, 4 hours and 24 hours after
                       commencing of therapy.
                                                  Index No:             Resp 2
POLICY ON NON-INVASIVE POSITIVE                   Date of Approval:
PRESSURE VENTILATION FOR TYPE 2                   Revision Date:        27/06/2010
     RESPIRATORY FAILURE                          Revision No:          2
                                                  Page No:              Page 7 of 22

           5.1.7  Monitor arterial blood gases 1 hour and 4 hours after
                  commencement of therapy, then as clinically appropriate.
                  Frequency of blood gas analysis will depend on whether
                  adjustments have been made. It will also depend on whether or
                  not the patient is a candidate for full ventilation. This decision
                  should be made early on. Repeated blood gases on a patient
                  who will not be a candidate for full ventilation adds little
                  benefit and the target saturation range is often an adequate
                  marker of therapy.
           5.1.8 Perform periodic chest x-rays when clinically appropriate to
                  monitor for the development of barotraumas i.e.: pneumothorax
                  or pneumediastinum.
           5.1.9 Adhere strictly to inclusion and exclusion criteria. See 7.1, 7.2,
                  7.3.
           5.1.10 To liaise with Dr Quigley/CNS Respiratory/ Respiratory
                  Physiotherapist.
           5.1.11 Inform patient and relatives of outcomes and discuss
                  expectations.

    5.2 Responsibility of The Clinical Nurse Specialist – Respiratory

           5.2.1   The CNS can set up and initiate NIPPV according to
                   prescription.
           5.2.2   Advisory and educational role for Medical and Nursing staff.
           5.2.3   Liaison with the multi-disciplinary team in relation to
                   developing and implementing respiratory policies and
                   protocols.
           5.2.4   Co-ordinating with the multidisciplinary team in caring for the
                   patient on NIPPV.
           5.2.5   Offering ongoing support and information for the patient with
                   respiratory disease and their families.
           5.2.6   The Nurse Specialist will co-ordinate the in-service education
                   programme for members of the Medical Team, Registered
                   Nurses (who work in an area where NIPPV is used), and
                   Chartered Physiotherapists. See Appendices

    5.3 Responsibility of The Nursing Staff

           5.3.1   The Staff Nurses on St Bridgets Ward who have attended the
                   NIPPV training can set up and initiate NIPPV according to the
                   prescription
           5.3.2   Nursing staff play a pivotal role in providing continuity of care
                   for the patient. It is important that the nurse is familiar with the
                   NIPPV.
           5.3.3   The patient receiving NIPPV must be cared for by a registered
                   nurse that has attended the training on NIPPV.
                                               Index No:             Resp 2
POLICY ON NON-INVASIVE POSITIVE                Date of Approval:
PRESSURE VENTILATION FOR TYPE 2                Revision Date:        27/06/2010
     RESPIRATORY FAILURE                       Revision No:          2
                                               Page No:              Page 8 of 22

          5.3.4   Nursing staff should inform a member of the medical team
                  immediately if the patients condition deteriorates significantly.



    5.4 Responsibility of Senior Physiotherapist in Respiratory Care

          5.4.1   Lead the Physiotherapy department involvement in the NIPPV
                  service
          5.4.2   Monitor and oversee the service provided by other
                  Physiotherapists and address issues arising from this
          5.4.3   Supervise and contribute to the development and training of
                  Physiotherapists in NIPPV
          5.4.4   Can set up and initiate NIPPV according to prescription
          5.4.5   Advisory and educational role for Medical and Nursing staff.
          5.4.6   Liaison with the multi-disciplinary team in relation to setting
                  up respiratory policies and protocols.
          5.4.7   Co-ordinating with the multidisciplinary team in caring for the
                  patient on NIPPV.
          5.4.8   Offering ongoing support and information for the patient with
                  respiratory disease and their families.
          5.4.9   The Senior Physiotherapist will co-ordinate the in-service
                  education programme, in conjunction with the Clinical Nurse
                  Specialist, for members of the Medical Team, Registered
                  Nurses (who work in an area where NIPPV is used), and
                  Chartered Physiotherapists. See Appendices.

    5.5 Responsibility of The Chartered Physiotherapist

          5.5.1   To undergo training in NIPPV by attending the 0.5 day
                  multidisciplinary team Workshop and the Physiotherapy in-
                  service training sessions.
          5.5.2   Prior to use, the Physiotherapist will complete the NIPPV
                  competency assessment with the Senior Physiotherapist in
                  Respiratory Care (or other appropriate member of staff) to
                  ensure that the staff are competent and that staff who do not
                  regularly work with respiratory patients keep up to date in this
                  area
          5.5.3   Having assessed the patient and made a clinical decision that
                  ventilatory support may be required, the physiotherapist will
                  liaise with the appropriate medical team to arrange a review of
                  the patients need for NIPPV
          5.5.4   Following prescription, the physiotherapist can set up and
                  initiate NIPPV
                                                 Index No:            Resp 2
 POLICY ON NON-INVASIVE POSITIVE                 Date of Approval:
 PRESSURE VENTILATION FOR TYPE 2                 Revision Date:       27/06/2010
      RESPIRATORY FAILURE                        Revision No:         2
                                                 Page No:             Page 9 of 22




6.0 Indications For Use:

      6.1 Type 2 respiratory failure (Acute or Chronic) e.g. COPD exacerbation,
          neuromuscular disease or chest wall deformities. Type 2 Respiratory
          failure can be divided into 2 groups:
              6.1.1 Patients with intrinsic lung disease charecterised by:
                     6.1.1.1 Ventilation/perfusion (VQ) imbalance
                     6.1.1.2 Inadequate alveolar ventilation
                     Type 2 Respiratory failure is precipitated by additional insult
                     usually infection eg. COPD exacerbation, Cystic Fibrosis
              6.1.2 Patients with intrinsically normal lungs but with inadequate
                     ventilation due to:
                     6.1.2.1 Neuromuscular abnormalties
                     6.1.2.2 Chest wall deformities (kyphoscoliosis)


      6.2 ARF Type 2 is defined by low PaO² < 8kPa and high PaCO² > 6.5kPa
          with or without reduced pH (acidosis)

             6.2.1   Ventilatory muscle dysfunction or muscle fatigue. Clinical
                     signs of ventilatory muscle fatigue or impending fatigue
                     include tachypnoea, use of accessory muscles, reduced tidal
                     volume and subjective complaints of fatigue and dyspnoea.
                     Note: Patients with developing fatigue may not exhibit overt
                     hypercapnia.
             6.2.2   Clinical signs of Type 2 Respiratory Failure include:
                     6.2.2.1 Tachypnoea
                     6.2.2.2 Accessory muscles of respiration
                     6.2.2.3 Tripod position
                     6.2.2.4 Abdominal breathing/pursed lip breathing
                     6.2.2.5 Cyanotic lips/tongue/tips of fingers
                     6.2.2.6 Tremors of hands
                     6.2.2.7 Bounding pulse
                     6.2.2.8 Conjunctival injection/suffusion
                                                 Index No:            Resp 2
 POLICY ON NON-INVASIVE POSITIVE                 Date of Approval:
 PRESSURE VENTILATION FOR TYPE 2                 Revision Date:       27/06/2010
      RESPIRATORY FAILURE                        Revision No:         2
                                                 Page No:             Page 10 of 22




7.0 Procedure

      7.1 Inclusion Criteria For NIPPV
             7.1.1 Blood gas abnormalities – De-compensated Type 2 Respiratory
                    Failure with Acidosis
                    PaO² < 8kPa on room air
                    PaCO² > 6kPa
                    pH 7.25 – 7.35
                    Respiration Rate > 24


      7.2 Exclusion Criteria

            7.2.1   Too Unwell to tolerate
                    7.2.1.1 Needs intubation
                    7.2.1.2 Haemodynamic/Cardiac instability
                    7.2.1.3 Severe upper GI bleed
                    7.2.1.4 Patient arresting

            7.2.2   Unco-operative Patient
                    7.2.2.1 Glasgow Coma Scale < 8
                    7.2.2.2 Unable to protect airway, unable to clear secretions,
                    high risk of aspiration

            7.2.3   Structural problems
                    7.2.3.1 Facial or neurological surgery, trauma or deformity
                    7.2.3.2 Upper airway obstruction
                    7.2.3.3 Pneumothorax

      7.3 Relative Exclusion Criteria

            7.3.1   Extreme Anxiety
            7.3.2   Massive Obesity
            7.3.3   Copious Secretions
            7.3.4   Pre-existing bullous lung disease
            7.3.5   Acute Asthma

      However the final decision of inclusion or exclusion will be made by the
      Registrar or Consultant.
                                                  Index No:             Resp 2
 POLICY ON NON-INVASIVE POSITIVE                  Date of Approval:
 PRESSURE VENTILATION FOR TYPE 2                  Revision Date:        27/06/2010
      RESPIRATORY FAILURE                         Revision No:          2
                                                  Page No:              Page 11 of 22




8.0 Persons Authorised To Prescribe NIPPV

      8.1 Prior to prescribing NIPPV

             8.1.1 Due to the specialised nature of NIPPV and the limited resources
                   available onsite, ordering and prescription is limited to the Consultant
                   or Registrar only.
             8.1.2 If outside normal working hours a registrar unfamiliar with
                   NIPPV has to contact the Consultant on call who can in turn
                   review the patient to prescribe NIPPV.
             8.1.3 The prescribing team should inform/consult either Dr Quigley
                   or Specialist Registrar in Respiratory, who will be available for
                   ongoing advice/consultation/patient review. This will apply to
                   outside office hours also.
             8.1.4 An early decision as to whether the patient will be for intubation
                   if NIPPV fails must be made and clearly documented by the
                   medical team in charge of the patients care.
             8.1.5 If the patient will be for intubation the Anaesthetist on call
                   should asked to review the patient.
             8.1.6 The patient must be handed over to the team on call that night if
                   set up during daytime hours.
             8.1.7 At weekends the consultant on call should review the patient at
                   ward round.
             8.1.8 The medical team caring for the patient will continue to be
                   responsible for the patient unless otherwise agreed with Dr
                   Quigley.

      8.2    Prescribing NIPPV


             8.2.1   The prescribing doctor must record the prescription for NIPPV
                     in the medical notes and the NIPPV prescription sheet.
             8.2.2   Target oxygen saturation must be recorded generally as a range
                     and bearing in mind the patient population. A target saturation
                     range of 90-94% is generally appropriate in the COPD patient.
             8.2.3   Changes to the settings must be prescribed and recorded on the
                     NIPPV prescription sheet.
             8.2.4   Clear instructions re: timing of arterial blood sampling – usually
                     after 1 hour and 4 hours, should be recorded in medical notes.
                     These times refer to the time after the target saturation has been
                     achieved/after the ramp time.
                                                 Index No:               Resp 2
 POLICY ON NON-INVASIVE POSITIVE                 Date of Approval:
 PRESSURE VENTILATION FOR TYPE 2                 Revision Date:          27/06/2010
      RESPIRATORY FAILURE                        Revision No:            2
                                                 Page No:                Page 12 of 22

             8.2.5   The patients resuscitation status must be made clear and
                     documented.
             8.2.6   All patients must still have conventional treatment with
                     nebulised bronchodilators, prescribed oxygen therapy,
                     antibiotics, steroids, theophyllines, diuretics etc.

9.0 Persons Authorised To Set-Up, Initiate And Make Adjustments According
    to the Prescription

             9.1 Members of the Medical Team, Respiratory Physiotherapist,
                 Charted Physiotherapists and Clinical Nurse Specialist (Respiratory),
                 Staff Nurses on St Bridgets Ward that fulfil the following criteria:
                     9.1.1 He/she is employed by the hospital.
                     9.1.2 He/she has attended the NIPPV workshop.
                     9.1.3 He/she must be aware of the following hospital protocol.
                            for the safe management of patients receiving NIPPV.
                     9.1.4 He/she feels competent to carry out the task.
                     9.1.5 Initially this should be done in consultation with either
                            Dr Quigley or the Specialist Registrar in Respiratory.


             9.2 Persons Unauthorised To           Set-Up,    Initiate    Or      Make
                 Adjustments to Prescription

                     9.2.1   Agency nurses.
                     9.2.2   Doctors, Nurses or Physiotherapists who have not
                             attended the NIPPV workshop.
                     9.2.3   Nursing, Medical and Physiotherapy students.


10.0 Clinical areas where NIPPV is used

      Patients that require NIPPV should be cared for in St Brigids Ward.


11.0 Storage of Equipment

          11.1 There will be one Respironics Vision NIPPV unit that will be kept in
               St Brigids Ward.
          11.2 Consumables (mask, tubing, filters and headgear) will also be kept
               with the machine.


12.0 Maintenance of Equipment

      12.1 To ensure that the equipment is in safe working order and is
                                                    Index No:            Resp 2
 POLICY ON NON-INVASIVE POSITIVE                    Date of Approval:
 PRESSURE VENTILATION FOR TYPE 2                    Revision Date:       27/06/2010
      RESPIRATORY FAILURE                           Revision No:         2
                                                    Page No:             Page 13 of 22

            physically clean.
       12.2 Store in a cool dry place.
       12.3 Cover when not in use.
       12.4 Nursing staff should ensure that all the non-disposable equipment is
            physically clean after patient use to reduce the risk of cross infection.
       12.5 Face Oils can perish mask so need to be cleaned daily.
       12.6 If a facemask becomes soiled it must be cleaned using water and a
            general detergent. Disposable facemasks can be used throughout the
            course of the therapy and should not be disposed of until the NIPPV is
            discontinued
       12.7 The maintenance and servicing of the equipment will be provided by
            MGI in conjunction with Biomedical Engineering in the Hospital


13.0   Preparing A Patient For NIPPV

       13.1   Psychological Support
              13.1.1 The psychological preparation of patients undergoing any
                     procedure/therapy has been shown to reduce anxiety. Anxiety is
                     a particular problem experienced by breathless patients and this
                     can exacerbate respiratory distress. The psychological care of
                     the patient should involve:
              13.1.2 Giving simple explanations of the treatment and ward
                     environment, ensuring that the information given is meaningful
                     to the patient.
              13.1.3 Keeping the patient and their family/significant other informed
                     of all aspects of their care, ensuring continuity in the
                     information given by the multi-disciplinary team.
              13.1.4 Allow the patient of their family/significant other time to
                     express any concerns or ask questions.
              13.1.5 Observing the patient for any signs of anxiety.
              13.1.6 Involving the family/significant other in the patients care where
                     appropriate.
              13.1.7 Referring the patient to the Clinical Nurse Specialist for
                     continuing support.

       13.2   Preparation
              It is important that before commencing NIPPV to ensure clinical and
              physiological baseline information is obtained about the patient. A
              complete history and full physical examination should be carried out by
              the medical team.

              This should include the following:

              13.2.1         Systemic arterial blood pressure and pulses paradoxes
              13.2.2         Pulse and respiratory rates
                                              Index No:             Resp 2
POLICY ON NON-INVASIVE POSITIVE               Date of Approval:
PRESSURE VENTILATION FOR TYPE 2               Revision Date:        27/06/2010
     RESPIRATORY FAILURE                      Revision No:          2
                                              Page No:              Page 14 of 22

           13.2.3         Skin colour, temperature and perfusion
           13.2.4         Use of accessory muscles of ventilation
           13.2.5         Paradoxical movement of the chest wall that may reflect
                          impending or actual ventilatory muscle fatigue
           13.2.6         Auscultation

           The following test should be completed:

           13.2.7         Arterial blood gases (ABG’s)
           13.2.8         Chest X-ray
           13.2.9         Pulse Oximetry (SaO²)
           13.2.10        ECG


    14.0 Initial Set-up

           14.1 It is important during the initial set-up that the settings are
                quickly adjusted to meet the clinical need of the patient and
                demonstrate an immediate clinical outcome:
           14.2 The NIPPV system should be assembled correctly away from
                 the patient’s bedside to reduce anxiety.
           14.3 Ensure that the correct tubing is attached to the mask and that
                the CO2 valve is clear and directed away from the patient’s
                neck.
           14.4 A resistance main flow anti-bacterial filter must be used. This
                should be fitted between the unit and the tubing. These should be
                changed after every 24 hours of use. Therefore a patient on
                continuous treatment changes once daily.
           14.5 Over the first 30 minutes the prescribing Doctor or Clinical
                Nurse Specialist – Respiratory or a Chartered Physiotherapist,
                who has attended the workshop on NIPPV, should work up the
                patient gradually to the prescribed pressure (ramp time). It has
                been proven that patients tolerate NIPPV better when starting it
                off slowly and explained carefully.
           14.6 The initial settings are based upon the clinical decision of the
                prescribing doctor. Start the pressure very low and increase as
                and when the patient is comfortable. Forcing an increase before
                they are ready will only result in the patient giving up with the
                treatment before you have even managed to reach the effective
                ventilation.
           14.7 Guidelines for initial settings are provided below:

          IPAP = 10cm H²O              Upper limits = 26cm H²0

          EPAP = 4cm H²O               Upper limits = 10cmH²0
                                                Index No:             Resp 2
POLICY ON NON-INVASIVE POSITIVE                 Date of Approval:
PRESSURE VENTILATION FOR TYPE 2                 Revision Date:        27/06/2010
     RESPIRATORY FAILURE                        Revision No:          2
                                                Page No:              Page 15 of 22


       These are rough estimates and depend on the patient size.
       Generally start off lower (7:4) and allow the patient to get comfortable
       with the mask at the lower pressures before slowly ramping up over
       approximately 30 minutes as tolerated, to the higher pressures, generally
       10:4 initially (8:4 for small elderly females). Increase the IPAP by 1, first
       at 5-10 minute intervals. Start off with a higher oxygen flow and then
       bring down to the target saturation.

           14.7   BiPAP System Mode

          Spontaneous/Timed - IPAP and EPAP as set out above.
                               Set rpm as indicated (this is a back up rate lower
                               than the patient’s actual respiratory rate. It will
                               be activated if patient becomes apnoeic or
                               respiratory rate falls below setting)


          FiO2 - Prescribed oxygen may be given via the hospital piped system
                  and piped in through the Vision NIPPV machine directly.



           14.8   Treatment times vary according to the patient’s tolerance
                  and arterial blood gases.



    15.0 Promoting Patient Comfort

           15.1 Patient comfort is crucial to the success of NIPPV.
                Members of the multi-disciplinary team must be alert to patient
                discomfort throughout the therapy and action must be promptly
                taken if the patient complains of discomfort.
           15.2 Consider using humidification if the patient complains of a dry
                mouth or/and is having difficulty expectorating.
           15.3 A hydrocolloid dressing can be placed on the bridge of the nose
                to provide a cushion and prevent abrasion.
           15.4 The head straps should be checked and adjusted as required.


    16.0 Mask Fitting

           16.1 Proper mask fitting has been shown to be a crucial component in
                the success of NIPPV. Mask comfort is often the limiting factor
                                               Index No:             Resp 2
POLICY ON NON-INVASIVE POSITIVE                Date of Approval:
PRESSURE VENTILATION FOR TYPE 2                Revision Date:        27/06/2010
     RESPIRATORY FAILURE                       Revision No:          2
                                               Page No:              Page 16 of 22

              to continuous use of mask ventilatory support. If the mask is too
              tight the patient will be uncomfortable and over time this may
              result in “pressure induced tissue ischaemia”. If the mask is too
              loose, it may result in air leakage and the system becomes less
              efficient.
         16.2 A properly fitted nasal mask should come close to, but not touch
              the nose in three places:

         1)     The bridge of the nose
         2)     On the sides of both nares
         3)     Just below the lowest point of the nose above the lip

         16.3 For mouth breathers the full-face mask can be used if required.
               This is generally easier and more effective to use in the acute
               setting.
         16.4 Head straps should be applied to the mask to ensure that the
               mask can be secured. Adjust straps so that all significant leaks
               can be eliminated. Over tightening of the mask should be
               avoided to prevent patient discomfort and distortion of the mask
               cushion. The mask seal can be confirmed by varying the
               patient’s head position. It is not necessary to eliminate all leaks,
               as the machine will automatically compensate.
         16.5 Use chin straps if the patient complains of excessive leakage
               from the mouth.
         16.6 To prevent abrasion and increase patient comfort, a patch of
               wound care dressing may be placed on the bridge of the nose.
         16.7 If the skin irritation results from a local allergy to the mask
               material the manufacturers suggest using a skin barrier such as
               Micropore tape or Duoderm.
         16.8 Change mask from nasal to full-face mask or vice-versa where
               appropriate.
         16.9 Observe patient for development of ear discomfort and
               conjunctivitis.
         16.10 Observe for abdominal distension or nausea, which can be due to
               swallowing large volumes of air.
         16.11 If a satisfactory degree of patient comfort is not achieved the
               continuation of the therapy should be reviewed by the medical
               team.
         16.12 The mask and tubing should be stored in a clear plastic bag with
               the patient’s name on it when the non-invasive ventilation is not
               in use.
                                                 Index No:            Resp 2
    POLICY ON NON-INVASIVE POSITIVE              Date of Approval:
    PRESSURE VENTILATION FOR TYPE 2              Revision Date:       27/06/2010
         RESPIRATORY FAILURE                     Revision No:         2
                                                 Page No:             Page 17 of 22


.
        17.0 Adjustment Of The NIPPV

              17.1 Adjustments to the NIPPV system are made on the basis of
                   physiological parameters and patient comfort. All changes to the
                   NIPPV system must be prescribed by the registrar on the NIPPV
                   prescription sheet and in the patient’s medical notes.

              17.2 Supplemental oxygen must be administered as prescribed and its
                   effectiveness monitored.


        18.0 Monitoring The Patient During NIPPV

              18.1 The patient must be monitored while on NIPPV to evaluate the
                   efficacy of treatment.
              18.2 These guidelines specify the minimum requirements for
                   monitoring; more vigorous observations may be required based
                   upon the patient’s clinical presentation.
              18.3 The patient’s subjective response to the therapy is crucial in
                   determining its efficacy.
              18.4 The patient’s responses must be monitored and recorded on the
                   NIPPV Observation Chart.
              18.5 Record

                     18.5.1 Respiratory rate, depth and pattern
                     18.5.2 Pulse rate and rhythm
                     18.5.3 Blood pressure – for signs of Hypotension, resulting
                            from reduced cardiac output/reduced vascular return
                     18.5.4 Pulse Oximetry (SaO²)
                     18.5.5 ABG's – 1 hour, 4hours and 24 hours
                     18.5.6 Peak flow/FEV¹
                     18.5.7 Observe and record signs of confusion, irritability and
                            other changes in mental function. The Glasgow Coma
                            Scale may be used for this.
                     18.5.8 Observe skin around mask area for skin irritation and
                            the bridge of the nose for a pressure ulcer
                     18.5.9 Observe skin colour for cyanosis
                     18.5.10Observe sputum for quantity, colour and consistency,
                            then record. If indicated medical staff should be
                            informed and a specimen sent for micro culture and
                            sensitivity.
                     18.5.11The NIPPV system settings should be checked to ensure
                            they are at the prescribed settings.
                                              Index No:            Resp 2
POLICY ON NON-INVASIVE POSITIVE               Date of Approval:
PRESSURE VENTILATION FOR TYPE 2               Revision Date:       27/06/2010
     RESPIRATORY FAILURE                      Revision No:         2
                                              Page No:             Page 18 of 22



    19.0 Weaning Off NIPPV

          19.1 Typical weaning off NIPPV is not necessary.
          19.2 A patient is taken off NIPPV and assessed to see if he/she is
               coping off the machine.
          19.3 Patients who are deteriorating will be put back on the NIPPV.
          19.4 Oxygen saturation and vital signs observations should be closely
               monitored. Any deterioration should be reported to the medical
               team.
          19.5 If SaO2 are deteriorating an ABG will be required to re-assess
               need for re-commencing NIPPV.


    20.0 Cleaning Equipment And Consumables

          20.1 All hospital staff must adhere to standard precautions when
                handling, as there is a risk of handling body fluids.
          20.2 This policy must be read in conjunction with the hospital
                Infection Control Manual.
          20.3 All staff caring for a patient on NIPPV must understand and
                comply with standard precautions and infection control
                standards related to cleaning equipment, maintaining equipment
                and handling of secretions.
          20.4 Hand washing is the most effective means of reducing the risk of
                cross infection.
          20.5 All non-sharp disposable equipment must be disposed of safely
                in health-care non-risk waste.
          20.6 Clean facemasks when they become soiled. They must be
                cleaned with sterile water and detergent and dried with a
                disposable paper towel.
          20.7 When not in use masks must be stored in a clear plastic bag.
          20.8 Masks and tubing are disposable after single patient use.
          20.9 The bacterial filter has to be changed between patients and every
                24 hours of use.
          20.10 If a patient is MRSA positive the inlet filter on the back of the
                machine will need changing after use.
          20.11 If a patient is suspected of having Mycobacterium Tuberculosis
                (TB) they must be cared for in accordance with the hospital
                Infection Control guidelines.
                                                   Index No:            Resp 2
 POLICY ON NON-INVASIVE POSITIVE                   Date of Approval:
 PRESSURE VENTILATION FOR TYPE 2                   Revision Date:       27/06/2010
      RESPIRATORY FAILURE                          Revision No:         2
                                                   Page No:             Page 19 of 22



       21.0 Implementation Plan

              21.1 It is the responsibility of the Clinical Nurse Specialist –
                   Respiratory to disseminate these guidelines in hard format to the
                   Director of Nursing, Senior Nurse Management Team, Clinical
                   Nurse Managers, Infection Control Nurse Specialist,
                   Physiotherapy Manager and Medical Staff in Wexford General
                   Hospital.
              21.2 It is the responsibility of all ward/line managers to bring these
                   guidelines to the attention of nursing staff.
              21.3 Ultimately it is the responsibility of each individual practitioner
                   to ensure they are familiar with current best practice guidelines.


       22.0 Resource Implications

              22.1 Regular education and in-service training for staff will be
                   provided in Wexford General Hospital as outlined in Section 5.
              22.2 Funding will be required to release staff for training
                   programmes.

       23.0 Revision History
            Not applicable

       24.0 Evaluation / Audit
             The content and structure of the guideline will be evaluated and audited
       in 6 months from date of approval.


       25.0 Bibliography


Baldwin David R., Allen Martin B. (1997) Non-invasive positive pressure ventilation
for the use of acute exacerbation of Chronic Obstructive Pulmonary Disease: use it
sooner rather than later to assist the respiratory muscle pump.
British Medical Journal, Vol. 314(7075), pp.163-164.


British Thoracic Society Guidelines for the Management of Chronic Obstructive
Pulmonary Disease (1997)
Thorax, Vol. 52, Supplement 5.
                                                    Index No:            Resp 2
 POLICY ON NON-INVASIVE POSITIVE                    Date of Approval:
 PRESSURE VENTILATION FOR TYPE 2                    Revision Date:       27/06/2010
      RESPIRATORY FAILURE                           Revision No:         2
                                                    Page No:             Page 20 of 22

Reynolds JE. (1997) Non-invasive positive pressure ventilation in acute respiratory
failure.
Journal of Emergency Nursing, Vol. 23, pp. 608-610.


Pauwels RA., Buist S., Calverly PM., Jenkins CR., Hurd SS. (2001) Global Strategy
for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary
Disease.,
American Journal of Respiratory and Critical Care Medicine. Vol. 163 (5) pp. 1256-
1276

Kramer N., Meyer TJ., Meharg J. (1995) Randomised, prospective trial of non-
invasive positive pressure ventilation in acute respiratory failure.
American Thoracic Society, Vol. 151, pp. 1799-1806


Plant PK, Owens JL, Elliot MW. (2000) Early use of non-invasive positive pressure
ventilation for acute exacerbation of Chronic Obstructive Pulmonary Disease on
general respiratory wards.
The Lancet, Vol. 335(9219), pp. 1931-1935


Preston R. (2001), Introducing non-invasive positive pressure ventilation.
Nursing Standard,Vol. 15(26), pp. 42-45.


Respironics guidelines on Ventilator Support Systems (1993) AARC Clinical
Practical Guidelines to Intermittent Positive Pressure Breathing,
Respiratory Care, Vol. 38, pp. 1189-1195



26.0   Appendices

       1)   Prescribing Notes
       2)   Suggested Settings
       3)   NIPPV Prescription Sheet
       4)   NIPPV Observation Sheet

Contact numbers
            Specialist Registrar in Respiratory Medicine via switchboard
            Dr Quigley via switchboard
            Samantha Conroy, Respiratory Clinical Nurse Specialist : bleep 135
            Marie Codd, Respiratory Physiotherapist : bleep 121
            Brian Marshall – Product Manager AIR Products : 087 87255334
            Nurse Specialist AIR Products: 087 7975698
                                           Index No:            Resp 2
POLICY ON NON-INVASIVE POSITIVE            Date of Approval:
PRESSURE VENTILATION FOR TYPE 2            Revision Date:       27/06/2010
     RESPIRATORY FAILURE                   Revision No:         2
                                           Page No:             Page 21 of 22

         Niall Byrne – Regional Sales Specialist AIR Products: 087 6397666
                                              Index No:           Resp 2
 POLICY ON NON-INVASIVE POSITIVE              Date of Approval:
 PRESSURE VENTILATION FOR TYPE 2              Revision Date:      27/06/2010
      RESPIRATORY FAILURE                     Revision No:        2
                                              Page No:            Page 22 of 22

The information contained in the attached document must be read and fully
understood by all staff.

Please print and sign your name when you have done so.

         DATE                    PRINT NAME                   SIGNATURE

				
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