Bipap question

JustBeachyNurse, LPN · Aug 3, 2015

I have a toddler patient on bipap HS. IPAP 22/EPAP 12. So 10/5 is much lower than this complex child. What does pulmonology say?

Dacatster, ADN · Aug 3, 2015

There is no pulmonolgist. This is a tiny community hospital trying to do big business in an area that they have no business in

JustBeachyNurse, LPN · Aug 3, 2015

Have you tried searching for EBP protocols for BiPap in children with acute exacerbation of asthma? I can't right now. I know numbers need to be adjusted for suspected atalectasis or decreased respiratory drive.

Dacatster, ADN · Aug 3, 2015

Does it matter if I tried? This is a nursing forum where we get advice from each other. Do you ask every person that asks a question if they tried looking it up first before they post?

I know I come across snippy. But in all defense it appeared to be a sarcastic answer. Just help or don't.

JustBeachyNurse, LPN · Aug 3, 2015

You cannot detect tone in written word. Your post is rather offensive and snippy making assumptions.

I asked if you looked at EBP as sometimes you may have come across journal articles in doing your research as a query nothing more nothing less. I said I couldn't right now as it was near midnight and I was on a mobile device, you made the assumption. My experience with medically complex children has higher pressure values and my previous research shows higher pressure numbers than you are reporting however since it was late and I was on mobile I was unable to link the article.

Responses like yours imply you have no interest in expanding knowledge base and want only instant answers that meet your needs...see what assuming intent from written word does?

Regardless of your written unorofessionalism, this article clearly states that in asthmatic children the higher pressures are necessary for improved outcome and much better than mechanical ventilation with zero incidents of "blown out lungs" (pneumothorax) and zero deaths.

Eur Respir Rev | Mobile

BiPAP Is Safe for Small Children with Acute Asthma - NEJM Journal Watch

You're welcome.

FlyingScot, RN · Aug 3, 2015

Does it matter if I tried? This is a nursing forum where we get advice from each other. Do you ask every person that asks a question if they tried looking it up first before they post?
I know I come across snippy. But in all defense it appeared to be a sarcastic answer. Just help or don't.

Sometimes we look up and attach articles only to find out the OP has already reviewed them but failed to mention it. It can be a big time suck for nothing. There was nothing sarcastic about JB's post. She even said she couldn't look them up for you at the moment. She then took the high road and went ahead and did it despite your offensive reply to her.

We are, as a rule, very happy to help on this forum but don't bite the hand that feeds you or you will find that people will be disinclined to assist you.

chare · Aug 3, 2015

Does it matter if I tried?[/quore]
Yes, it does. So many times someone comes here asling questions and they haven't even done a basic search.
This is a nursing forum where we get advice from each other.
I find it somewhat concerning that you would rely on information you receive from an anonymous online forum. This reinforces the need to actually research your question usingb reputable sources.
Do you ask every person that asks a question if they tried looking it up first before they post?
Yes, actually many of us that post here do. You will find that members here are more likely to assist you after you have shown some effort to help yourself.
I know I come across snippy. But in all defense it appeared to be a sarcastic answer. Just help or don't.
Yes, you not only came across as snippy, this was extremely rude. Had this response been directed at me, I would not have replied further. It speaks well of JustBeachyNurse the he or she not only responded and procvided you two excellent resources.

JustBeachyNurse, LPN · Aug 3, 2015

High flow oxygen can do more harm than good especially in a child with an asthma exacerbation. Current EBP is to NOT give high flow O2 to everyone but titration oxygen based upon ABGs or SpO2 depending on the value readily available. Even EMS is transitioning away from NRB mask at 15LPM for everyone.

BiPap reduces the vent/perfusion mismatch, promotes opening of the smaller airways by maintaining a constant pressure during inspiration and exhalation with minimal negative effects and little to no barotrauma or pneumothorax risk.

If it were me, I would ask the intensivist out of curiosity (though it sounds like you asked in an accusatory tone and created a defensive relationship) in the hopes he could explain the rationale and perhaps cite current research I might not be aware of that's available.

BiPap/CPAP for sleep apnea and other conditions is not the same as for an acute exacerbation of asthma or COPD. The settings are very different.

heinz57 · Aug 3, 2015

High flow oxygen can do more harm than good especially in a child with an asthma exacerbation. Current EBP is to NOT give high flow O2 to everyone but titration oxygen based upon ABGs or SpO2 depending on the value readily available. Even EMS is transitioning away from NRB mask at 15LPM for everyone. .

The way the OP wrote HiFlow and being this is peds, I would hope this is blenderized O2 ranging from 21% to 100%.

Everybody should do away with NRB masks because they are not HiFlow and are very dangerous but not just because of a potential for high FiO2.

BiPap reduces the vent/perfusion mismatch, promotes opening of the smaller airways by maintaining a constant pressure during inspiration and exhalation with minimal negative effects and little to no barotrauma or pneumothorax risk. .

With any positive pressure device there is always risks involved especially in the hands of those who are not familiar with them.

If it were me, I would ask the intensivist out of curiosity (though it sounds like you asked in an accusatory tone and created a defensive relationship) in the hopes he could explain the rationale and perhaps cite current research I might not be aware of that's available..

Considering both the RT and the nurse here were both questioning "10/5", the physician probably was taking a very, very conservative approach figuring neither were overly comfortable with Bipap or kids.

BiPap/CPAP for sleep apnea and other conditions is not the same as for an acute exacerbation of asthma or COPD. The settings are very different.

No, that is not always correct. In fact you linked to an article which used the Respironics model my father used at home for OSA. The patient you have on Bipap was probably transitioned with similar settings using a hospital machine and chances are the hospital will take those same setting in consideration again if that patient has to be in their care. Work in a children's hospital and you will see we mix and match machines all the time. Sometimes for convenience of the hospital and sometimes for medical necessity. The key is knowing limitations of the care providers and the patient. If a patient is being moved to a medical floor, no need for those nurses to learn the ICU machine. Often the child will do alright on a little Respironics home model.

heinz57 · Aug 3, 2015

My hospital has frequently been using bipap on all or asthma patients instead of HiFlow O2. What is the highest acceptable setting? My last two patients were 3 and small 7 year old. The setting was 10/5 looked too high a setting. I am nervous this intensivist is going to blow a lung with the pressure being so high. Even RT has questioned the setting. No budging from the dr.

You did not mention what type of Bipap was being used. For some 10/5 has a delta p of only 5 and the total PIP is only 10. For others it is a delta p is 10 and total PIP is 15. But, even still that is considered a very low and generic setting. It is usually one which a doctor orders as a starting point and hopes someone with have enough sense to titrate to the patient's clinical settings. You would have to look at the patient for breath sounds, vitals and over all comfort. On the machine you would have to look at the volumes (VT and MV), RR and graphics. The CXR would be very helpful. Please do not think you need an ABG as someone suggested. For kids, a vbg or cbg will do just fine.

I think the doctor was fighting against you and the RT who seemed to not understand Bipap or kids. Had the doctor agreed to low the settings, that could have done way more harm than going a little higher which is what the child might have benefited more from. This was probably the doctor's compromise to keep from increasing the child's work of breathing and harming them from settings too low. I seriously think the RT needs to do a rotation in pediatrics or at least get an inservice on the Bipap machine to feel more comfortable. Nursing should also do this. In our ER, nurses and some ER techs manage all Bipap. Nurses manage all Bipap machines in the step down and medical floors.

You just have to understand the machine and the specific lung conditions. Reading the literature is of little use if you aren't familiar with the machines they are using. It would be very difficult to just copy the numbers as I mention before about the delta p.

Also the links posted, one mentioned an ICU ventilator and an old Respironics machine which was used many years ago in home health for OSA. The other is the NEJM which requires a subscription. Even most hospitals in today's economy, can't afford it. A mere blurb is useless since you need to know more about the machines.

~PedsRN~, BSN, RN · Aug 4, 2015

Wow, I'm surprised this is a "thing"! I can't imagine a 3 year old complying with a Bipap? I have a hard enough time strapping a NC on their face!