Bipap question

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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.

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!

When kids are sick enough for Bipap in an asthma exacerbation, they will tolerate it just fine. If they are fighting it, HFNC will be used. For the Bipap we use adult nasal masks as full face masks for the little ones. Peds' nurses can be very convincing and creative so rarely do we have any problems.

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Specializes in PICU.

To OP: You didn't really explain why you were concerned that 10/5 BiPAP was too much for a 3 year old. The only thing you said was you were concerned the pt would "blow a lung." But every medical intervention (or lack there of) needs to be thought about in terms of the physiology involved and the potential risks and benefits. Why would you use BiPAP on an asthma patient? What is the respiratory physiology of asthma that you are trying to overcome? How is that different from an RSV Brochiolitis patient? What happens to your patient if they can't be maintained on BiPAP? You seem to think Hiflow would be prefereable, why? I really am not sure why these settings were concerning to you.

Asthma is a restrictive lung physiology with air trapping. Your goal is to open the airways and reduce the work of breathing. Hiflow is good at dead space removal in an infant, but isn't going to do anything for an asthma patient. You need pressure in asthma to overcome airway resistance. The pressure can also help stent open the airway and lesson some of the air trapping. The risk with using too high of pressures (the reason you generally want to be careful titrating PEEP (or EPAP) is you don't want to end up with lungs that are so overdistended that you are no longer getting good air exchange. A chest x-ray can help you see how overdistended the patient is.

Although there is a risk of pneumothorax with BiPAP, that is a risk in asthma regardless. They can get a spontaneous pneumo if they are pulling so hard to breathe. Also, BiPAP is still much better than being intubated. Intubating an asthmatic should always be avoided if at all possible. Pushing air into lungs that are constricted and full of secretions is just a bad mix. At least with BiPAP they are still doing a lot of the work and that should minimize the actual pressures that the alveoli are seeing. When you have to sedate them to keep them intubated, they lose their ability to control their breathing and lose all negative inspiratory force. But even an intuabted asthmatic on a PIP of 45, the alveoli still aren't seeing that much pressure, because of the airway constriction.

In the end, the patient needs whatever settings they need to reduce their work of breathing and keep them from being intubated. If 10/5 is working for the patient, then you go with it. I agree with the other posters who said that next time ask the doctor to explain why he feels like BiPAP is the best option for the patient. Clearly they felt like it was the right decision in that situation.

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Asthma is a restrictive lung physiology with air trapping. Your goal is to open the airways and reduce the work of breathing. Hiflow is good at dead space removal in an infant, but isn't going to do anything for an asthma patient. You need pressure in asthma to overcome airway resistance. .

Actually asthma is more obstructive than restrictive by definition. Restrictive and constrictive sometimes are confused.

HFNC which also has heated humidity works wonders on patients of all ages. Kids we can easily go up to 15 L to decrease their work of breathing. For smaller ones we try to stay under 10 L HFNC. Adults can go up to 70 L/min by HFNC. We will allow small (less than 10 kgs) to eat and drink at 4 L or less.

Unless the child just looks like they are going to fatigue now, we will go with HFNC first. And then there is always heliox.

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There is no "maximum limit" per say. Every patient is different, it is not a device you set and forget. The IPAP needs to be titrated to ensure the measured tidal volumes are in normal ranges for the child's IBW, generally we look for Vt's at least 5ml/kg IBW while on NPPV. EPAP should start at at least 5cm, if it's an acute setting. A CXR will better dictate what you set the EPAP, you may want more if there's atelectasis, or a really bad P/F ratio.

You'll know immediately if the settings are appropriate, based on 1. pt's physical response (reduction in neck and intercostal retractions, belly breathing, nasal flaring, etc), 2. reduction of resp rate and heart rate, 3. ABG's. Based on the ABG you'll know exactly how you need to revise the settings, if the pt is still acidotic you should increase the delta P between EPAP and IPAP to improve the ventilatory aspect, this is also known as pressure support. If the oxygenation is still bad, an increase of EPAP may be of use, but remember, increasing the EPAP without increasing the IPAP will yield less pressure support, so the pt may lose some ventilation in that scenario and could become tachypneic once again. NPPV is only as effective as the clinician managing it, need to look at "the big picture".

Bipap is an acceptable means of therapy in someone with acute resp. compromise(and chronic, if bad enough), especially if it means preventing an intubation. Of course, as long as there's no contraindications for it, and keen monitoring is vital! I've had a couple respiratory arrests in front of my eyes with acute asthma pt's on bipap. They can tire out very quickly on you.

As far as HFNC goes, it really depends on the patient, commonly patient's that have primary oxygenation issues will benefit from HFNC. Ventilation issues are better met with NPPV. In kids, HFNC can create a peep effect on them, which can help their work of breathing, oxygenation and sometimes ventilation...but if their gas is crappy (

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It's really a case-by-case matter, and like I said "the big picture".

Sometimes Respiratory Therapists tend to miss "the big picture".

Nurses need to be advocates for the patients. ABGs are not always necessary. Save the artery for a possible A-line if the patient becomes hemodynamically unstable and pressors are initiated. VBGs are just as useful. You can get info from the other lab values to learn just about anything you want to know especially when it comes to a medically complex child who also has RAD.

Nurses can also see that fluids, corticosteroids and mag if necessary are initiated early. Nurses can also do asthma scores to ensure the proper amount of bronchodilators are given. Too many under dose on continuous nebulizers. MDIs are the way to go if the patient isn't at the continuous albuterol stage or is weaned off. Too many want to do "blowby" nebulizers which are useless for delivery.

Ensuring the child stays hydrated is essential. Not every child should be on Bipap. Granted a Bipap machine is a great source of revenue for RT where as the HFNC is treated just like a NC for charges, it is does not have to be set up for everyone. HFNCs are also on blenders. Keep the flows higher and wean the FiO2. Not every child tolerates Bipap and many are nauseous from their air hunger and the meds. You do not want a child vomiting into a full face mask or that could be a death sentence. Using large amount of sedation and restraints should be a very, very last resort. Bipap is not to be used as a ventilator. Intubate before too late. Again this is something the RN must stay on top up since RTs are usually only at the bedside for a few minutes "to check numbers". Bipap is very useful as I stated earlier but the advantages of the HFNC and other factors of the bigger picture which aren't always considered by RTs should be well noted. RNs have the bigger picture and must get more educated and trained to manage respiratory therapy equipment including Bipap. RTs are stretched too thin or some just don't stick around to see "the big picture".

There are other clinical signs which RNs should be aware of and assessing which might be a better predictor than some of the numbers on the Bipap. A restless child and a mask don't always give the best numbers on a Bipap machine but the RN at the bedside should have an assessment baseline to anticipate changes.

Nurses should also be reviewing the patient's home medications and lifestyle and making some suggestions for change according to an asthma plan. Most nursing departments in children's hospitals will have nurses who are certified asthma educators to help physicians initiate the plans for discharge.

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I understand where you are coming from. There was a reason why I said case-by-case basis.... not every patient needs bipap and not everyone can tolerate it either. Frankly it is difficult to tolerate. FWIW, heated HFNC can be billed as a different charge as NC, I use HFNC often and whenever possible as it's far more comfortable and pt compliance is very good.

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Specializes in Complex pedi to LTC/SA & now a manager.

I should add that my patient has a medical complex history and most of my patients are ex preemies & ex micro preemies. The toddlers rarely have an asthma diagnosis but "reactive airway disease" or BPD r/t prematurity. It was just an example that IPAP10/EPAP5 is not necessarily a too high of a setting that increases the risk of "blowing out a lung" but the settings need to be individualized to patient needs and response. This client tolerates a pediatric nasal bipap mask as long as the child's pre-bed routine is followed. One step out of order and be ready for an all night party!!

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Specializes in Acute Care Pediatrics.
When kids are sick enough for Bipap in an asthma exacerbation, they will tolerate it just fine. If they are fighting it, HFNC will be used. For the Bipap we use adult nasal masks as full face masks for the little ones. Peds' nurses can be very convincing and creative so rarely do we have any problems.

I work inpatient acute care in a large Children's hospital... we get the sickest of the sick and have never seen BiPap used for asthma. Maybe it is something they are using as a last resort in the PICU, I can't vouch for that. I am going to ask though, because it's fascinating. :) We use BiPap on the floor often for our very ill chronic children.

I am just envisioning the kiddos who continuously pull their NC off, tegaderm and all, complying with a bipap. You can't tape one of those suckers on. LOL!

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I work inpatient acute care in a large Children's hospital... we get the sickest of the sick and have never seen BiPap used for asthma. Maybe it is something they are using as a last resort in the PICU, I can't vouch for that. I am going to ask though, because it's fascinating. :) We use BiPap on the floor often for our very ill chronic children.

I am just envisioning the kiddos who continuously pull their NC off, tegaderm and all, complying with a bipap. You can't tape one of those suckers on. LOL!

We will use the Respironics V60 Bipap machine in the ER, PICU and tele.

Google "pediatrics v60 asthma". There is a good PPT by Julie...

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Specializes in NICU, PICU, PCVICU and peds oncology.

I am just envisioning the kiddos who continuously pull their NC off, tegaderm and all, complying with a bipap. You can't tape one of those suckers on. LOL!

No, you can't - but the head gear is pretty hard to get out of. The straps need to be snug enough to prevent leaks. Not to say some kids DON'T get out of it, but it's not as likely as the NC-pullers.

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Specializes in Pediatric Critical Care.

I had a 3 month old on bipap 10/5 the other day....didnt blow their lungs :)

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Specializes in Pediatric Critical Care.
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!

Being three makes everything harder! I've often seen then given a touch of precedex to help them tolerate the mask if its needed. Bubble CPAP and masks on an infant are hard as well!

I work inpatient acute care in a large Children's hospital... we get the sickest of the sick and have never seen BiPap used for asthma. Maybe it is something they are using as a last resort in the PICU, I can't vouch for that. I am going to ask though, because it's fascinating. :) We use BiPap on the floor often for our very ill chronic children.

I am just envisioning the kiddos who continuously pull their NC off, tegaderm and all, complying with a bipap. You can't tape one of those suckers on. LOL!

Its great for asthma! I was once in a small community peds unit with a doc that wasn't used to having patients that were sick enough to be intubated, but we had a very sick asthmatic kid, about 9 years old. After about 6 hours of continuous nebs, the doctor wanted to intubate (it was dinner time and I think he wanted to go home soon)....but we begged him to just TRY bipap first. The kid stayed on bipap overnight and looked like a new boy in the morning, was able to speak full sentences, eat, back to q4 hours albuterol. Bipap can avoid intubation and thats a huge deal for an asthmatic!

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