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Sunday, November 23, 2014

The Noninvasive Ventilation Creed

What follows is what will be added to the new addition to the Real Physician's Creed: How to take care of Pesky RTs. Again, this is TOP SECRET information for physician use only, and was never intended to be released among the RT community.

My source for this ESOTERIC information will be kept anonymous, because if his peers find out he is the leak, he will be banned from the medical community at best, or ridiculed at worse. 


(Section B-3)
Physician's Real Creed: The Noninvasive Ventilation Creed:

Noninvasive ventilation (NIV)systems are complicated systems that require extensive training physicians don't have time for.  So, in lieu of spending thousands of dollars better spent on cigarettes and alcohol, allow me to simplify NIV so it's easy to memorize and requires little thought.  

There are essentially NINE rules for NIV: 

1. Know the types of NIV and when they should be ordered:
  • CPAP: prescribed for observed apnea or just simply obesity
  • BiPAP: for everything else
2.  Know the indications for NIV and how it works: 
  • Pulmonary Edema: it forces fluid out of the lungs
  • Respiratory Failure: it breathes for them
  • Hypoxic hypoxemia: it forces oxygen into the lungs
  • Hypercarbia/ CO2 >45 It sucks CO2 out of the lungs.  Warning: Do not wait for CO2 to rise above 47.  If it's 46, it's time for BiPAP.
  • Annoyed physician:  If either the patient or RT annoys you
3.  Know there are no contraindications, especially if you're too busy to consider intubation: 
  • DNR: put it on anyway
  • Unconscious/ Obtunded: fluid rarely builds up inside the mask, so it's well worth the risk.
  • Restraints: same as unconscious
  • Apneic: use BiPAP because it breathes for them
4.  Know that you can adjust the settings at any time without notifying a respiratory therapists. In fact, this can be done occasionally to boost your ego or tick off annoying RTs.  If they suspect you did it, deny, deny, deny.  

5.  Settings: Always order 10/4.  Increase settings aggressively to reach and maintain a pH of 7.40 and CO2 of 40.  FiO2 should start at 40% and adjust to maintain a PO2 of 106. Or, just pull any numbers out of your head and stick with them no matter what RT says. 

6.  Special considerations:  The increased pulmonary pressure will keep fluid out of the lungs and prevent pulmonary edema.  Works well for the following situations.
  1. Unable to give lasix on dyspneic patient 
  2. Need to give fluid bolus on dyspneic patient you are afraid to give lasix to due to hypotension (or any other reason)
7.  Length of time on BiPAP for effectiveness to be reached is two hours.  For this reason, it's important to talk patients into it, or have respiratory therapy force the BiPAP mask onto the patient, for at least two hours.  It's rare, although fine, for the patient to be anxious during this time. After the two hour time frame is up the patient may be allowed to refuse. A proper order for this is "Intermittent BiPAP." 

8.  May be indicated for low blood pressure.  Yes, we know that respiratory therapists keep saying that BiPAP is proven to decrease cardiac output and reduce venous return in order to reduce fluid in the lungs. When they say stuff like that just sigh and walk away. We KNOW that BiPAP can piss a patient off, and in this way raise blood pressure. It works well even better when combined with a continuous ventolin infusion. 

9. You do not need to order an ABG to prove BiPAP is necessary.  If the patient looks like a COPDer or CHFer, order BiPAP.  Here's what RT might say, "Dr. Do you want me to do the ABG before setting up BiPAP so we can verify that it's needed?"  To this you respond, "Do 'em in whatever order you want, just put the BiPAP on at some point so he can breathe better." So then the RT comes at you with the following ABGs: pH 7.4, CO2 40, HCO3 24, PO2 51, SpO2 86."  The RT says, "He says he's breathing great now that I increased his nasal cannula flow to 3lpm from 2lpm.  His SpO2 is now 95%."  Look, it doesn't matter what the RT says, nor what the numbers say, in this case you must stick with your initial hunch.  It's BiPAP all the way baby! 

10.  Know that BiPAP therapy is basically a glorified IPPB therapy. So, again, it may  be ordered as "intermittent BiPAP" for PaCO2 >45.  It also may be ordered as glorified BiPAP (i.e. Intermittent BiPAP) to ward off evil spirits. 

11.  CO2 Retention with normal or normalizing pH. So ABG results show a pH of 7.29 and a CO2 of 79. You know the CO2 is normally in the mid 50s. This is an ideal place to order BiPAP intermittently. This way you can gradually get the CO2 down to the patient's normal range. It's okay to order even if the patient is awake and alert and in no respiratory distress. It's okay to order this especially if the RT grumbles and gripes about it. 

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