Mini CPAP approved by FDA

It would be nice if we had a picture of this. But, at the present time, none are available. However, ResMed has announced that the FDA has approved the world's smallest CPAP machine, called the Air Mini. The product will be launched later this year.

The machine is small enough to fit easily into a travel bag. It is also small enough to fit into the pouch on the back of seats on airplanes. The company suggests that it will be an easy to operate secondary CPAP machine.

They will probably market it to medical equipment providers, noting that it will be another means for making a profit. It will benefit patients because it should improve compliance and convenience. They also say it is silent and comfortable.

I wonder how long it will take before we see one of these in the hospital setting. I wonder how long it will be before someone comes up with an iCPAP.

Further reading:

• ResMed: FDA clears world's smallest CPAP
• RT Magazine: FDA greenlights ResMed's Air Mini CPAP

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Patient Education: CPAP -vs- BiPAP

The following was originally published at healthcentral.com/copd on April 17, 2015.

CPAP -vs- BiPAP: What You Need To Know

Some people with COPD, or COPD plus sleep apnea, may benefit from CPAP or BiPAP. So what are these, and how might they benefit you?

Ventilation. Your lungs make sure you are taking in enough oxygen and blowing off carbon dioxide. Oxygen is an essential element in the air that your cells need to make energy. Carbon dioxide (CO2) is a waste product made by cells. An inhalation of an adequate depth is required for adequate ventilation to occur.

Diseases like COPD and Sleep Apnea may compromise ventilation, making it so you are not taking in enough oxygen and/ or blowing off enough CO2.

COPD. The disease process increases resistance in your airways, forcing you to work hard to take in a breath. This causes shallow breathing, causing areas inside your lungs that do not stay patent, a medical term for open. Less ventilation occurs, causing your oxygen levels to fall and your CO2 levels to rise.

Sleep Apnea. Soft upper airway tissue may collapse while you are sleeping, causing you to stop breathing for ten seconds to a minute. You may have up to 30 such episodes during a typical night. During these episodes you are not inhaling oxygen, causing your oxygen levels to drop. You are also not blowing off CO2, causing your CO2 levels to rise. This can make daytime living difficult, and may even increase your risk of dying while you are sleeping.

So, what are CPAP and BiPAP, and how might they help? They are non-invasive machines that supply a pressure to keep your airway patent and to assist you with your breathing.

CPAP. This is an acronym for Continuous Positive Airway Pressure. A continuous flow of pressure is applied during inspiration and expiration. It keeps your alveoli patent to assure adequate oxygenation. It keeps your upper airway patent to prevent apnea.

BiPAP. This is an acronym for Bi-Level Positive Airway Pressure. It provides a combination of IPAP and EPAP.

1. IPAP. This is Inspiratory Positive Airway Pressure. It is a pressure during inspiration that assists your inhalation (makes it easier to inhale). It makes sure you are ventilating, or taking a deep enough breath to blow off CO2. It also makes breathing easier by allowing you to rest your respiratory muscles.
2. EPAP. This is Expiratory Positive Airway Pressure. It is the same thing as CPAP, only it’s called EPAP when used with a BiPAP machine. It simply makes sure your airways stay patent so the next breath comes easier.

Sleep study. This is necessary to determine if you need CPAP or BiPAP. You will be hooked up to a variety of monitors, and a sleep technician will monitor you while you are sleeping. If you have apnea episodes, or if your oxygen levels drop, the technician will determine what pressures are ideal for you.

Home. Your doctor may determine you need CPAP or BiPAP at home. These are set up by home health care providers for you to wear every night. They fit nicely on a nightstand, and are usually very quiet and comfortable.

Hospital. When you are having a COPD flare-up, a doctor may prescribe CPAP or BiPAP to help you breathe better. These are used short term to buy time for other therapies ordered by your doctor to start working, such as bronchodilators, corticosteroids, antibiotics, and diuretics.

These are usually set up and managed by a respiratory therapist like myself.

Masks. There are a whole assortment of nasal pillows, nasal masks, face masks, and full face masks for you to try. Your home health provider will help you find which one that works best for you.

Compliance. Most people find that the benefits of using these machines -- such as improved quality of life -- make them very easy to get used to. Of course it helps that modern machines and masks are made with your comfort in mind. So if your physician recommends you try CPAP or BiPAP, please give it a try. You may find that it greatly improves your quality of life.

Further Reading.

• Your Journey Down the Respiratory Tract
• The Link Between COPD and Sleep Disorders
• My interview with Roxlyn Cole, a COPD patient using BiPAP
• Asthma and COPD: Basic Mechanisms and Clinical Management, page 842
• CPAP -vs- BiPAP: What RTs Need to Know

NIV proven useful for COPD, CHF, yet failure rates still high

Noninvasive ventilation (NIV), either in the form of Noninvasive Positive Pressure Ventilation (NPPV) or Continuous Positive Airway Pressure (CPAP), has been used in the critical care setting since the end of the 1980s, and is now commonly used in both Europe and the United States for the treatment of COPD exacerbatons and heart failure.

Studies also show that NIV may significantly decrease work of breathing, either by improving minute ventilation (COPD) or by decreasing venous return to the heart (CHF), and thereby reducing the need for intubation to 15% (although it is as high as 38% in patients with chronic respiratory disease).

However, despite it being so commonly used, and despite all the advancements in technology and equipment that have improved patient comfort, studies continue to show that anywhere from 20-30% of patients fail.  Of the patients who fail, 30-40% require intubation and mechanical ventilation.

A good indication of failure, or a good predictor of who will fail, is hypercapnia after initiation of NIV.

Contou et al, however, concluded that experienced respiratory therapists may make adjustments at the patient interface (mask) or changes in settings that make the experience more comfortable and more effective, thus resulting in a reduction in NIV failure rates to under 15%, thereby reducing mortality rates to 5%.

Contou et al also showed that, by using an NIV protocol and having the patient closely monitored in by experienced personnel, including a nurse and respiratory therapist, 48% of patients who were semi-comatose responded well to NIV therapy without the need for intubation.

The study shows that trialing patients on NIV in an experienced unit where the patient was closely monitored, even those who would otherwise have been intubated, has proven to be effective, thus further reducing the need for intubation.

Likewise, the researchers reported, "it has been shown that NIV failure was not associated with an increased mortality rate in hypercapnic patients; thus, delayed intubation in some patients likely did not worsen their outcome."

The bottom line here is that NIV protocols that allow the nurse and respiratory therapist to closely monitor and adjust the settings on the NIV "might reduce the intubation rate.

References:

1. Contou, Damien, Chiara Fragnoli, Ana cordoba-Izquierdo, Florence Boissier, Christan Brun-Buisson, and Arnaud W. Thille, "Noninvasive Ventilation for Acute Hypercapnic Respiratory Failure:  Intubation Rate in an Experienced Unit," Respiratory Care, December, 2013, volume 58, number 12, pages 2045-2052

Oxygenating with home BiPAP and CPAP machines

When using a ventilator, either for mechanical ventilation or noninvasive ventilation, a fixed FiO2 is set during ventilatory support. This is the best way of supplying supplemental oxygen to patients, especially because it may be adjusted to maintain a desired saturation.

However, when using a patient's home noninvasive ventilation equipment, either set up for BiPAP or CPAP, oxygen is typically placed directly into the circuit using a constant flow.  When this occurs, the amount of oxygen actually inhaled depends on a variety of factors:

• Oxygen flow
• Leakage
• Circuit
• Interface (face mask, nasal mask, etc.)
• Location of where oxygen is bleed into the system

Studies are still inconclusive as to where the best place to insert the oxygen into the system.  Some therapists place it near the machine, while others place it near the patient interface.  Ideally, the oxygen flow should be adjusted to maintain a desired Spo2.  This may be important for patients who are using their home units in the hospital setting.  

For patients who present in acute respiratory failure, when adequate oxygenation is not obtained with a patient's home unit, a ventilator (which may include a noninvasive ventilation device such as a Vision or V60) should be used in order to deliver a fixed FiO2 that can be easily adjusted to maintain an adequate SpO2.

References:

1. Storre, Jan H, Sophie E. Huttmann, Emelie Ekkernkamp, Stephan Wlterspacher, Claudia Schmoor, Michael Dreher, and Wolfram Windisch, "Oxygen Supplementation in Noninvnasive Home Mechanical Ventilation: The Crucial Roles of CO2 Exhalation Systems and Leakages," Respiratory Care, January, 2014, volume 59, number 1, pages 113-119

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What are the advantages of NIV?

Sometimes there is confusion regarding the advantages of NIV, otherwise referred to as BiPAP. I have had doctors order it because it "forces fluid out of the lungs" in heart failure, and because it "increases blood pressure." Yet neither of these are actual benefits of NIV. That said, what are the benefits of NIV? The are:

1. IPAP increases ventilation and helps to blow off CO2 
2. CPAP increases FRC and therefore keeps the lungs open so the next breath comes in easier
3. Both IPAP and CPAP help to reduce work of breathing
4. Both the IPAP and CPAP help reduce work of heart

So, how does BiPAP reduce work of heart because the increased intrathoracic pressure decreases preload to the heart, thereby decreasing cardiac output, and thereby decreasing blood pressure.  In this way, it helps to decrease the patients work of heart.  That is how it helps with heart failure.  It does not force fluid out of the lungs. It does not increase blood pressure.

Alternative therapies for status asthmaticus

So you have a really bad asthmatic in the emergency room, and you already have him on a continuous bronchodilator breathing treatment, and the nurse has already given intravenous epinephrine and solumedrol.

Now you, the RN and the doctor are willing to grasp at straws to prevent that person from needing to be intubated. What are some choices you might be able to recommend to the ER physician?

A book called Fatal Asthma and CMAJ list some of the most common "alternative therapies."

1. CPAP: This can be started to help the patient overcome his increased work of breathing. Adding CPAP is also a great technique of overcoming instinsic PEEP that causes hyperinflation. The problem with this is that asthmatics already feel as though they are suffocating, and this might make matters worse.

However, with good equipment, good coaching, and a doctor willing to apply to the patient some sedatives, this might be worth a shot if you have a compliant patient.

2. BiPAP: All the principles of CPAP apply here, except this also applies pressure with inspiraton to help the patient take in a deeper breath, thus allowing the patient to blow off some CO2. This may be of particular use if you suspect impending respiratory failure associated with a rising CO2.

I have seen BiPAP work on at least five asthmatics in the past couple years. Usually if a patient is bad enough to require noninvasive ventilation, we skip CPAP and go right to BiPAP.

3. Heliox: This is a helium/ oxygen mixture that consists of 80% helium and 20% oxygen. With the exception of hydrogen, helium is the lowest density of gas. And, according to medscape.com, since asthma is a disease associated with narrowed passages that result in turbulent flow and increased airway resistance, heliox can help create a more laminar flow, and thus decrease the work of breathing

According to studies, some patients benefit from this and others do not. So, while this is used in some hospitals, the jury is still out on whether it is a cost worthy investment for hospitals.

So now you have a patient in status asthamticus intubated in your emergency room. You have tried all the conventional therapies, and you once again are grasping at straws. What are some options?

4. Bronchiolar lavage: Also known as lung lavage. This is done with a fiberoptic bronchoscope and washing the bronchioles out with normal saline with the intent of clearing the lungs of mucus plugs. This is still not commonly done in a crisis, but remains an option.

5. Anesthetics: These are used to relax airway smooth muscles. According to Fatal Asthma, "Rapid, dramatic improvement is reported, leading to more effective ventilation and in some cases early extubation."

Ketamine is a smooth muscle relaxant and antihistamine, and is given intravenously. Of course this medicine is a known hallucinogenic, and it is a sedative. Many doctors prefer to wait until a patient is intubated to use it, and follow it up with a paralytic, as you can read here.

Isoflurane is an anaesthetic and bronchodilator that has been proven to be efficacious in ventilated patients in status asthmaticus. According to this study, " Isoflurane improves arterial pH and reduces partial pressure of arterial carbon dioxide in mechanically ventilated children with life-threatening status asthmaticus who are not responsive to conventional management."

6. Permissive Hypercapnia: This is something I'd wish doctors where I worked would consider more often. We had an asthmatic a few years back who was admitted to CCU, and the doctor ordered a tidal volume of 750. Since I was bagging the patient, and her lungs were stiff, like ventilating a brick. When I finally got her hooked up to the vent the highest tidal volume I could get was 150. The doctor was irate. But I was right. He finally admitted as much.

So, the point with permissive hypercapnia is that you allow a high CO2 and low pH at the expense of low pressures and a lower tidal volume and an appropriate respiratory rate to allow time for the patient to fully exhale to prevent air trapping. You do this while continuously trying to get the patient's airways to open up. In this patient's case, it took two days for this to happen.

As the author's of Fatal Asthma state, "Prolonged severe hypoxemia can cause devastating neurological injury and death, prolonged hypercapnia per se is thought to have no long-term adverse consequences. Use of permissive hypercapnia has become standard practice in many intensive care units and in general has rendered unnecessary other 'heroic' measures in the critically ill asthmatic patient."

Well, those are some of the options available to today's physicians for the treatment of status asthmaticus unresponsive to conventional therapies. Where I work we've used BiPAP and Bronchiolar lavage, although rarely.

I've known about heliox and permissive hypercapnia, but the anaesthetics used to treat status asthmaticus is something new to me. If these medicines were ever used at my facility I'm unaware of it.

If any of my readers know of any other alternative therapies for asthma please share them in the comments below.

Here's a great reason why RTs are NEEDED

We RTs think alike. A great example of this just occurred to me.

I was minding my business taking care of a real COPD patient in ER, when I was paged by a nurse in recovery. I called her.

She said, "We have a patient down here who has sats in the mid 80s, and I can't get them up no matter what I do."

I said, "What device are you using?"

"A face tent."

"Well, that explains why--"

"Dr. Umabalabamalamala wants you to set up CPAP when the patient gets upstairs."

"Why does he want that."

"Because he thinks the patient isn't taking deep enough breaths."

"Umm, CPAP doesn't help patients take in deep breaths," I reassured her.

"Well, that's what he ordered."

So, as the patient rolled into her room I disconnected the face tent from the patient and plugged in a nasal cannula, set it at 5lpm, and connected it to the patient. The spo2 was initially 85%.

"See," the recovery RN said, "That's the sat we kept getting in recovery. No matter what we did it wouldn't go higher."

Just then the SpO2 jumped up to 94% and stayed there. "Are you breathing okay," I said to the patient.

The patient said, "I'm breathing fine. Do I have to wear that thing. I was on it last week and I hated it."

"I will call your doctor," I said. She smiled.

I got the CPAP changed to prn. I said to the pt. "You saved yourself from this machine because you're so healthy." Again, she smiled.

The moral of this story: Hospitals NEED RTs.

Now, ironically, just after this happened, I return here and check out My RT Life, where the Trauma Junkie wrote about what hospital life would be like without RTs. So, I am linking to his excellent post here.

Not only did the doctor have no clue what a CPAP machine does, neither did the nurses have the knowledge to question the order. And neither one of them had knowledge enough of oxygen therapy to maintain an SpO2 without invasive therapy.

Yes, America, we RTs are needed.
Click here to learn the basics about CPAP.

Monday's class: My response to your queries

This post is my weekly attempt to answer Internet search engine queries that lead someone to clicking onto my medblog.

I know that most people click on my site and leave two minutes later frustrated that my site is not what they were looking for. When, in actuality, if they would have hung around a bit, had a cup of coffee with me, they may have found the answer they were looking for.

This is what I'm going to make an effort to do every Monday.

1. vomiting bipap: This is a good question and something that was covered extensively in RT school. There are two types of masks patients can wear who are using BiPAP. There is a nasal mask, and a full face mask. If the patient is wearing a nasal mask, then there's no problem. However, in the hospital setting we use full face masks probably 90% of the time. And, if someone is throwing up with a mask on their face, their risk of aspiration (inhaling the vomit into the lungs and risking pneumonia) increases big time. Take the mask off if a patient is vomiting. If the patient is in the hospital and is on BiPAP to prevent him from needing a vent, intubation might need to be considered to protect the airway.
2. giving mucomyst without a bronchodilator: Mucomyst has the ability to break up thick secretions and making them easier to spit up (theoretically). It can cause bronchospasm, and should always be given with a bronchodilator, such as Albuterol.
3. vaponephrine dose for kids: At Shoreline we use 0.5cc Vaponephrine on all kids. It's safe. I have rarely ever notices an increase in heart rate as a result of this medicine, and usually if the heart rate does increase, it's because of the kid crying because he's annoyed by the RT.
4. efficacy of albuterol with chf: I've repeated this many times on this blog, but Albuterol will do nothing for CHF unless -- UNLESS -- the patient also has an underlying bronchospasm component. If you want to try one treatment to see if it does anything, go for it.
5. is a nurse above a respiratory therapist: Absolutely not. We are a team. Now, RNs are know to have a little more respect in society, but that is slowly changing. The reason is that nurses have been around since the Civil War, and RTs are only just getting started. RNs also get paid more than RTs, but that's only because of the nursing shortage and, partially, because of the respect thing. But, all in all, we are a team.
6. azthmacort: I took asthma cort for about 15 years, and never had much success with it. The main reason for this was compliance, as I was prescribed to use it four times a day. I think it's better to use a steroid inhaler that allows you to use it twice a day to increase compliance. I have better success with Flovent or Advair, but there are other options.
7. barriers to being a good respiratory therapist: Lack of respect I think is the main barrier. And lack of protocols that allow us to really excell at providing the best care to our patients at the least cost to the hospitals. However, due to lack of respect by doctors, many hospitals still do not have respiratory therapy or patient driven protocols. That's a shame, I think, and is the biggest barrier in my mind.
8. albuterol blow-by neonates: I find that most babies do not tolerate masks, however the results of using a mask may vary from patient to patient. If the child is sick enough, he or she might not care. Also, a blowby may result in the loss of 80% or more of the medicine to the atmoshphere. That said, giving a blowby is often better than doing nothing for a child who is having true bronchospasm.
9. should i give my daughter albuterol for croup: Only if there is underlying bronchospasm. Albuterol does absolutely nothing for croup.
10. cpap therapy for copd how it works: CPAP works to improve oxygenation. It helps a patient oxygenate better, and thus allows more oxygen to get into the bloodstream.
11. congestive heart failure croupiness: We hear this a lot in CHF patients. And, more often than not, RNs and RTs mistake this for a wheeze and recommend or order breathing treatments. Actually, this is caused due to increased secretions or fluid in the upper airway, and will not go away with a treatment. I would say that abaout 80% of CHF patients, patients with pulmonary edema, will have this harsh, upper airway, stridorous, croupy sound. This is something they should teach in school, but I'm not sure they do.
12. what is my internet time: Huh?
13. extra shift incentive pay respiratory: What do you mean by extra shift? Do you mean overtime. We get paid overtime for anything over 40 hours just like everybody else.
14. bad experiences with advair: Some people have bad experiences with Advair mostly becaue it has Serevent in it, which can make a person shakey and irritable. I would recommend weaning yourself onto the Advair slowly, instead of starting right out taking it twice a day. I'm patenting that idea. I recently wrote a post about this, check it out by clicking here.
15. stridor and aerosol therapy: See my answer to question #9.
16. duoneb and hyperkalemia: It would be the equivelent of taking an asprin for a heart attack. Need I say more.
17. why respiratory therapists are disrespected: I tried to explain this in my answer to #7 above. Maybe one of my fellow bloggers can word it better than me with a comment.
18. my doctor gave me potassium after an asthma attack why and what does potassium do f: Hopefully he gave potassium because lab results showed hyperkalemia, not because of some frivolous idea that one treatment of Albuterol will decrease Potassium. However, for a further answer, see #16 above.
19. definite sign of impending alcoholism: Okay, sorry sir or maam, but you had to read all of the above to learn that I do not have an answer to this question. Now, I could gather a pretty good educated guess, but I'm pretty sure you'd rather hear from a professional in that area rather than a lowly RT.
20. respiratory therapist 12 hours: I do not know of any hospitals where the RT does not work less than 12 hour shifts.
21. does albuterol breathing treatments make baby sleepy: Actually, it can be soporiphic. I know for it fact it puts some babies and even some adults asleep. Ah, maybe this gives me another idea for an 'olin.

If you have a question I have not addressed here, or if you want an answer right now, feel free to contact us anytime and we'll get you an answer ASAP. You can contact us at Freadom1776@yahoo.com, or RTcave@yahoo.com.

That concludes today's class.