Bipap and oral medications

[Superman_RN]

Ok, so I was working a shift where I had this nightmare of a patient who was severely anxious, experiencing extreme shortness of breath, and had laryngeal edema. Patient came from outpatient center and was immediately put on Bipap, ABG, Mag sulfate, solumedrol, breathing treatment, the whole nine yards. We managed her without the need for intubation. ABG's showed slight respiratory alkalosis because of her asthma exacerbation and anxious hyperventilation. Since then, saturation at 100% on Bipap and RR 20. That's a little background. Now the question is, RIGHT before she went up to the floor, doc decided to order 40 PO of potassium chloride. Mind you, I had been in this patient's room almost every 10 min because she was freaking out about everything. So I gave the PO potassium. Now I realize it may have been better to do IV BECAUSE she was on Bipap but her potassium was not extremely low and to be honest, I wanted this lady up as soon as possible because she called me literally every 5 min. Next doc comes on and as she was reviewing her chart she freaks out because of the PO meds scolds me as to why I gave the PO meds. Knowing this doc, she may even report me. So was I right in giving PO meds to a pt with Bipap or is that contraindicated? Please help shed some light on this issue.

Thanks.

[itsmejuli]

Weren't you worried about her aspirating?

[Christy1019, ASN, RN]

Well of course if someone requires bipap its not IDEAL to take it off for things like that, however there are many situations where it is unavoidable. I once had a pt who was hyperkalemic and fluid overloaded, on bipap. In addition to the other meds to treat hyperkalemia they had kayexalate ordered. Now I BELIEVE you can give it rectally, however doing that to an alert, already anxious person on bipap was not feasible, so the bipap was temporarily taken off, med given, mask put back on, no problem.

I honestly don't see what this doctor could write you up for, it was a valid order, and it was administered without complications (or so I'm assuming from the info given). I wouldn't sweat it, tell them if they have an issue they should take it up with the ordering physician.

[Superman_RN]

You are right. The possibility of her aspirating occurred to me afterwards but my thinking was so distorted at the time I didn't realize until afterwards. Po meds went down fine and there were no complications although next time just to be safe I will always do IV instead of PO. I just wanted to know if it was contraindicated or if it was a preference.

[Superman_RN]

Thank you for your answer Christy. That clears things up. And yes, no complications with meds whatsoever. This doc just has a nasty attitude but I wanted to know the correct info for future references.

[Loo17]

It wouldn't have hurt to ask the doc if he wanted to order IV instead since the patient was on bipap but as long as you took the mask off while giving the pills you did nothing wrong. You followed an order. Many patients I have cared for end up staying on bipap for a while and are prescribed to receive their daily meds to control blood pressure, diabetes etc orally. Sometimes I even have orders to allow the patient sips of water prn because their mouth gets dry.

[MunoRN, RN]

PO intake that can leave residue in the upper airway is the main concern; once the Bipap is put back on the residue is more likely to be aspirated due to the Bipap airway pressure.

Many Docs are fine with meds however, since in theory they shouldn't leave residue and once they are past they go down you should be in the clear, although you still need to consider that many people requiring BiPAP may not be alert enough to swallow safely.

What I would have done is asked Dr. #2 to hold the scolding for a minute, call Dr. #1 and give the phone to Dr. #2.

[NICU Guy, BSN, RN]

As a sleep technologist for 13 yrs, we use CPAP/BiPAP daily and have never had an issue with patients taking their oral meds before bed. They are used in homes all the time without fear of aspiration. Granted they do not use them 24/7 but they still take their pills and put the mask on.

[SwansonRN]

In the ICU our doctors order PO meds all the time on our continuous BiPap patients (much to my annoyance at times). As long as they're awake and able to swallow and the mask isn't still half on it should be fine. The patients are usually excited to get a sip with their meds.

Based on the way you describe the patient she seemed awake enough to me

[Altra, BSN, RN]

If the patient was alert enough and had sufficient respiratory effort to tolerate a brief break from BiPAP there is no absolute contradindication. Doc needs to chill.

[zmansc, ASN, RN]

I don't see an issue. I would have asked the second doc, why she thought PO meds was an issue. Was it the BIPAP or the laryngeal edema? Those K+ pills are huge and I could see her being worried they would get stuck if her airway was constricted. If she was acting like you should not give PO meds to anyone on BIPAP, I would disagree with that. As long as the pt's airway is patent, they can clear it, and the BIPAP has helped them to reduce the anxiety enough so they can feel comfortable with the mask off for a few seconds to get the pill and a sip of water down, no issues. Now if the airway is constricted to the point where there is concern for not being able to swallow (and in this case the pill is huge) then I might reconsider. However, since the pt was able to swallow this pill without issue, it apparently was not so constricted to be a problem.

[Sassy5d]

I've done that several times and never would have given it a thought. Never had an issue. Some docs just like to complain to complain.