NRB & COPD your input please

[crb613]

I had a pt come in the other night severe resp. distress. We had little hx on the pt at the time except COPDer, and he could not talk (working to breathe). He was diaphoretic, rr 30+ guppy breathing, tachy,lethargic. Sats with good wave form 70%. Lungs sounded like crap. EMS had him on 4l nc.

RT was there took him off oxygen to get room air ABG, then back on 4l. During this sats dropping rapidly down to 60% and they were not coming up....rr increasing along with hr.

I wanted to put him on a NRB, another nurse said no he's a retainer.....waht are you thinking??? I was a little upset with this.....my response was so we let him code & then do something? My thinking if you need oxygen you need oxygen.... treat what you see in front of you. His ABG ph 7.2, PCO2 60, HCO3 30.

Just wondering how you all would respond to a pt like this?

btw...I posted this in pulmonary also to gain more feedback

[GilaRRT]

There is actually some interesting data out there on CPAP versus BiPAP ™. It may not be as clear cut as BiPAP is more effective. Depending on your source, BiPAP is associated with a higher incidence of potentially lethal complications such as MI. My point being, it is often patient dependent and not as simple as some may think. Anecdotally, I find people often go for BiPAP ™ because that is what they have always done, but have not really taken time to appreciate the literature or take the differences from patient to patient into consideration.

[GreyGull]

The industry has realized the issues concerning BiPAP™ and has responded with a new generation of technology.

BiPAP™ was not intended to be a "ventilator" but some often believe it to be and set the rate as they would for an AC mode.

I also agree that CPAP might work well in some situations better especially if one does not understand bilevel or BiPAP™. If the machine does not allow for active breathing with a sophisticated exhalation valve at the higher level, the patient may increase work of breathing.

The ABG only gives a limited snap shot. The way we have traditionally taught ABGs leaves a lot to be desired.

[tewdles, RN]

Both CPaP and BiPaP are sometimes useful for palliating symptoms in hospice patients.

[ZippyGBR, BSN, RN]

Let me just throw this question out to see how people are thinking: Everybody appears to have a BiPAPA ™ bias, assuming a patient is a good candidate for NIV, why would you choose BiPAP ™ over CPAP and visa versa?

CPAP improves oxygenation by increased alveolar recruitment

BiPAP encourages gas exchange and helps to remove CO2

CPAP for type 1 resp failure or pulmonary odema

BiPAP for type 2 resp failure

http://www.lunguk.org/you-and-your-lungs/diagnosis-and-treatment/non-invasive-ventilation-niv - 'patient' information but covers a lot of the key points of why NIV and why BiPAP in particular.

Uk national guidelines 2008 RCP(lond) /BTS / ICS

http://bookshop.rcplondon.ac.uk/contents/85efff68-58d4-4382-a48e-1e5f20c6187d.pdf

and

http://www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/NIV/Guidelines/NIVinCOPDFullguidelineFINAL.pdf

an example of a local guideline

http://www.newcastle-hospitals.org.uk/downloads/clinical-guidelines/Clinical%20Support%20Services/NIV2010.pdf

[GreyGull]

Both CPaP and BiPaP are sometimes useful for palliating symptoms in hospice patients.

That is an interesting topic that might deserve a heading all to itself.

We will also put DNR patients on NIV if we feel it is a short term situation. Sometimes it is a gamble and the patient doesn't turn around as expected. NIV falls into a gray area of ventilation and it can become just as complex as withdrawing from an ICU ventilator.

Here is a decent guideline and questions or info you can use to prepare a family or patient.

http://www.palliativedrugs.com/download/091209_combined_Withdrawing_NIV_Draft_Guidelines_Revised231009.pdf