Return VT on BIPap DURING POSITIONAL CHANGES

1. Return VT on BIPap DURING POSITIONAL CHANGES Charlotte Burns, SRT Robyn Borkowski, SRT Kimberly Sizemore, SRT Shawn Thomas, SRT Claire Washington, SRT Support and equipment was provided by Lone Star- Kingwood College Respiratory Dept.

2. Hypothesis We hypothesize that patient positioning does in fact play a vital role in the delivery of tidal volumes during bi-level positive airway pressure.

3. Biological Question Will changes in body position affect the return VT on a healthy adult getting BiPAP?

4. Abstract • 12 healthy test subjects were placed in supine, semi-Fowlers and high Fowlers positions while receiving BIPAP at 10/8 cmH20. The tidal volumes was recorded in different positions. • There was no significant change in tidal volume with positional changes. • Only two out of twelve subjects had a percent change greater than fifteen percent.

5. Background Patient positioning plays a vital role in the success of NIPPV. Current guidelines indicate that the patient should be in an upright sitting position, or lying down in the supine position with the head of the bed (HOB) elevated 30 degrees or greater. Slouching is discouraged because it impairs diaphragmatic movement, and results in decreased inspired tidal volumes.

6. Background Non invasive positive pressure ventilation (NPPV) is now a common device used in hospitals and home care facilities on a daily basis. According to Mosby's Respiratory Care Equipment "the first successful use of non invasive positive pressure ventilation (NPPV) was recorded as early as the mid eighteenth century." (Cairo, pg 773).

7. Background Cont’d. In the 1940's Motley and colleagues at Belleuve hospital studied the use of NPPV on patients with pneumonia, pulmonary edema, near drowning, Guillain Barre syndrome, and acute severe asthma. In the 1960's PEEP was used in the treatment of acuter respiratory distress syndrome (ARDS). By the 1970's care givers were able to understand the effects on invasive ventilation and the lung damage it can cause, so researchers went back to NPPV.

8. Background Cont’d. In the 1980's NPPV became widespread and many different brands and modes were developed. In 1987 one study showed the successful use of NPPV in three patients with post infection muscle weakness and two with muscular dystrophy. This demonstrated that NPPV could be used and effective in long term settings and diagnosis. In 1989 Meduri and colleagues were successful in avoiding intubations with the use of NPPV in eight out of ten patients.

9. Background Cont’d. Indications: • Bi-level positive airway pressure therapy delivers two different pressure settings for the patient. Patients who have been treated with BIPAP have breathing disorders beyond sleep apnea. BIPAP is useful in CHF patients and many other types of disorders, particularly patients who have high CO2 retention. (www.ezinearticles.com) • *Restrictive thoracic disorders, (progressive neuromuscular disease or severe thoracic cage abnormalities) • *Severe chronic obstructive pulmonary disease (COPD) • *Central sleep apnea (CSA)

10. Background Cont’d. Indications: • *Obstructive sleep apnea (OSA) • **Arterial Blood Gas (ABG) PaCO2 (+/=) 45 mm Hg, while awake on normal FIO2 • **Spo2 (-/=) 88% for at least five consecutive minutes on normal FIO2 • ** Mean Arterial Pressure (MAP) greater than 60cm H2O or FVC greater than 50% of predicted (progressive neuromuscular disease only) (www.healthlink.com)

11. Background Cont’d. Hazards: The BIPAP is intended to be used with special masks or connectors that have exhalation ports to allow continuous flow of air out of the mask. When the device is turned on and functioning properly, new airs from the device flushes the exhaled air out through the mask exhalation port. However, when the device is not operating, enough fresh air will not be provided through the mask, and exhaled air may be re-breathed. Re-breathing of exhaled air for longer than several minutes can in some circumstances lead to suffocation.

12. Background Cont’d. Contraindications: • The BIPAP should not be used if you have severe respiratory failure without a spontaneous respiratory drive. If any of the following conditions apply to you, consult your physician before using the device. • Inability to maintain a patent airway or adequately clear secretions in compromised person • At risk for aspiration of gastric contents • Diagnosed with acute sinusitis or otitis media

13. Background Cont’d. Contraindications: • Allergy or hypersensitivity to the mask materials where the risk from allergic reaction outweighs the benefit of ventilator assistance • Epitasis, causing pulmonary aspiration of blood • Hypotension in compromised person

14. Glossary • Acute Severe Asthma-Asthma is a common disease that results in reversible airway obstruction that could lead to air trapping. • Acute sinusitis- severe, sudden onset inflammation of one or more para-nasal sinuses • Acute Respiratory Distress Syndrome (ARDS)- is a severe lung disease caused by a variety of direct and indirect issues. It is characterized by inflammation of the lung parenchyma leading to impaired gas exchange with concomitant systemic release of inflammatory mediators causing inflammation, hypoxemia and frequently resulting in multiple organ failure. This condition is often fatal, usually requiring mechanical ventilation and admission to an intensive care unit. A less severe form is called acute lung injury (ALI).

15. Glossary • Arterial Blood Gas (ABG) is a blood test that is primarily performed using blood from an artery. The test is used to determine the pH of the blood, partial pressure of carbon dioxide and oxygen, and the bicarbonate level. • Aspiration- the act of inhaling, especially in the reference to the pathological aspiration of vomitus or material foreign to the respiratory tract • CO2 retention is a pathophysiologicalprocess in which too little carbon dioxide removed from the blood by the lungs. • Central Sleep Apnea- during sleep the brain temporarily stops sending signals to the muscles that control breathing. Central sleep apnea often occurs in people who are seriously ill. For example, it can develop in persons who have life-threatening problems with the brainstem.

16. Glossary • Chronic obstructive pulmonary disease (COPD) is a disease of the lungs in which the airways become narrowed. This leads to a limitation of the flow of air to and from the lungs causing shortness of breath. In contrast to asthma, the limitation of airflow is poorly reversible and usually gets progressively worse over time. This is also associated with air trapping.

17. Glossary • Congestive Heart failure is the inability of the cardiovascular system to perfuse the body tissue. This may be due to cardiomyopathy, MI, or increased vascular resistance, excessive fluid or interference by increased thoracic pressure. • Conjunctivitis- inflammation of the eye • Diaphragm- is a sheet of muscle extending across the bottom of the ribcage. The diaphragm separates the thoracic cavity from the abdominal cavity and performs an important function in respiration • Endotracheal intubation- placement of a tube through the nose or mouth through the larynx, vocal cords, and into trachea. • Epitaxis- bleeding from the nose

18. Glossary • Exhalation port- is the area that the patient exhales through • Expiratory-pertaining to the expiration of air from the lungs. • FiO2, in the field of medicine is the fraction of inspired oxygen in a gas mixture. The FiO2is expressed as a number from 0 (0%) to 1 (100%). The FiO2 of normal room air is0.21 (21%). • Gastric Distension Aerophagia- is a condition that occurs when a person swallows too much air, which goes to the stomach causing abdominal bloating and frequent belching and may cause pain. • GuillainBarre-is an acute inflammatory demyelinatingpolyneuropathy (AIDP), an autoimmune disease affecting the peripheral nervous system, usually triggered by an acute infectious process resulting in paralysis of the ventilatory muscles • Hypersensitivity- of or pertaining to a tendency of the immune system to exhibit an excessive or exaggerated response against environmental antigens that are not normally harmful

19. Glossary • Hypotension- an abnormal condition in which the blood pressure is not adequate for normal perfusion and oxygenation of the tissues • Inspired-the act of drawing air into the lungs in order to exchange oxygen for carbon dioxide, the end product of tissue metabolism. • Mean Arterial Pressure(MAP) a national average blood pressure in an individual. It is defined as the average arterial pressure during a single cardiac cycle • Muscle weakness (or "lack of strength") is a direct term for the inability to exert force with one's muscles to the degree that would be expected given the individual's general physical fitness. A test of strength is often used during a diagnosis of a muscular disorder before the etiology can be identified

20. Glossary • Muscular dystrophy (MD) refers to a group of genetic, hereditary muscle diseases that cause progressive muscle weakness. Muscular dystrophies are characterized by progressive skeletal muscle weakness, defects in muscle proteins, and the death of muscle cells and tissue. • Obstructive Sleep Apnea (OSA) is a common sleep apnea caused by obstruction of the airway. It is characterized by pauses in breathing during sleep... • Otitis media- an inflammation in the middle ear (the area behind the eardrum) that is usually associated with the buildup of fluid which may or may not be infected.

21. Glossary • Oxygen saturation (SO2), commonly abbreviated as "sats", measures the percentage of hemoglobin binding sites in the bloodstream occupied by oxygenPaCO,n partial pressure of carbon dioxide in the blood. Critical in regulating breathing levels and maintaining body pH

22. Glossary • Patent Airway- open or unblocked airway • Positive end-expiratory pressure (PEEP) is a term used in mechanical ventilation to denote the amount of pressure above atmospheric pressure present in the airway at the end of the expiratory cycle. The equivalent in a spontaneously breathing patient is CPAP. PEEP is set on the ventilator. On the BiPap machine, this is called EPAP. • Pulmonary Edema- is swelling and/or fluid accumulation in the lungs. It leads to impaired gas exchange and may cause respiratory failure

23. Glossary • Sleep apnea (or sleep apnea in British English is a sleep disorder characterized by pauses in breathing during sleep. Each episode, called an apnea(Greek: ἄπνοια (ápnoia), from α- (a-), privative, πνέειν (pnéein), to breathe), lasts more than 10-20 second • Supine position-is a position of the body; lying down with the face up. • Tidal Volume (Vt)-is the lung volume representing the normal volume of air displaced between normal inhalation and exhalation when extra effort is not applied. • Tracheotomy or tracheostomy- are surgical procedures on the neck to open a direct airway through an incision in the trachea (the windpipe).

24. Subjects • Subjects were gathered from Lone Star Community College Kingwood • We had informed consent forms signed and witnessed. • Test subjects were given detailed written instruction

25. Equipment • universal circuit 1,000 series • small and medium nasal mask with strap • bacterial filter 22mm OD with 15 mm ID • hand held pulse ox by Tuff Sat • Bi-PAP ST-D model # 332003 • Manufacturer Respironics Huntsville, Pennsylvania • There is no calibration for the Bi-PAP ST-D

26. Study Procedures • Gathered equipment and made sure that we had 12 test subjects... we explained the procedure to them and had them sign the consent form... • then we accessed each test subjects heart rate, respiratory rate, and SAT before the procedure and during • Next we turned on the Bi-PAP and attached the nasal mask to the test subject with the Velcro straps making sure that a minimal leak of < 20 was present. • Next, we set the IPAP 8 and EPAP 5, and the test subject were on room air. We placed the pulse ox on the test subjects and monitored the heart rate, respiratory rate, and SAT during the whole procedure to make sure the test subjects were stable

27. Study Procedures Cont’d. • We started with the test subjects in the supine position... we then observed the test subjects tidal volumes and wrote down the better of three for each subject. • We then changed the test subjects’ position to the semi-fowler and observed the tidal volumes as we did in step 3. • Last we put the test subjects in the high fowler position and observed the tidal volumes just like we did in steps 3 and 4.

28. Study Procedures Cont’d. • Upon completion of the procedure we compared the test subjects tidal volumes from each position to see if the subject position did affect the return tidal volume.

29. Data and Statistics

30. Data and Statistics Cont’d. • Previous slide had all original data from the 3 positions that the subjects were in and the Tidal Volumes they produced.

31. Data and Statistics Cont’d.

32. Data and Statistics Cont’d. • Average Vt in males in supine position= 740 • Average Vt in males in semi-fowler position= 687 • Average Vt in males in high-fowler position=723 • Average Vt in females in supine position= 662 • Average Vt in females in semi-fowler position=697 • Average Vt in females in high-fowler position=674

33. Data and Statistics Cont’d

34. Data and Statistics Cont’d • Average Vt for a Caucasian in supine position= 686 • Average Vt for a Caucasian in semi-fowler position=681 • Average Vt for a Caucasian in high-fowler position= 670 • Average Vt for an African American in supine position= 652

35. Data and Statistics Cont’d • Average Vt for an African American in semi-fowler position =675 • Average Vt for an African American in high-fowler position=650 • Average Vt for an Asian in supine position 777 • Average Vt for an Asian in semi-fowler position=833 • Average Vt for an Asian in high-fowler position=820

36. Data and Statistics Cont’d • Average Vt for a Hispanic in supine position=558 • Average Vt for a Hispanic in semi-fowler position=561 • Average Vt for a Hispanic in high-fowler position=577

37. Data and Statistics Cont’d

38. Data and Statistics Cont’d • Average Vt for a right handed person in supine position=679 • Average Vt for a right handed person in semi-fowler position=680 • Average Vt for a right handed person in high-fowler position=744

39. Data and Statistics Cont’d • Average Vt for a left handed person in supine position=709 • Average Vt for a left handed person in semi-fowler position=853 • Average Vt for a left handed person in high-fowler position=824

40. Data and Statistics Cont’d

41. Data and Statistics Cont’d • Range supine 441-936 • Range semifowler 453-885 • Range highfowler 416-893 • Median in supine 635.5 • Median in semifowler 686 • Median in highfowler 685.5

42. Discussion • Based on our finding there was not a significant change in tidal volume based on positional changes. • Only two out of twelve subjects had a percent change greater than fifteen percent.

43. Discussion Limitations: • Time and money • Limited number of test subjects • Study was only done on healthy people • Nasal mask only not full face mask

44. Discussion New biological questions: It would be nice to see this test done on: • Patients that have sleep apnea (OSA and CSA) • Patients with restrictive disorders • Patients with COPD • Sleeping test subjects

45. Conclusion The differences between the test subjects’ tidal volumes were not significant in the positional changes, therefore we conclude that moving the patients’ positions had no benefit on the return tidal volume of healthy awake individuals.

46. References (Becker, et al., 1993, pp. 184-188) Becker, H., Brandenburg, U., Peter, J.H., Schneider, H., Weber, K., & Von Wichert P. (1993). Indications and application of BiPaP therapy. Pneumologie, 47 (Suppl.). Retrieved February 1, 2009, from http://www.biomedexperts.com/Abstract.bme/8497477/Indications_and_application_of_BiPaP_therapy. Benditt, J. O. (2006). Full-time Noninvasive Ventilation: Possible and Desirable. Respiratory Care, 51(9), 1005-1015. Cairo, J. M., & Pilbeam, S. P. (2003). Introduction to Ventilators. In Mosby's Respiratory Care Equipment (7th ed., pp.303). St. Louis, MO: Mosby, Inc. Cairo, J.M., & Pilbeam, S.P. (Eds.). (2004). Home-care, Transport Devices, Alternative Devices. In Mosby's Respiratory Care Equipment (7th ed., pp.646-649). St. Louis, MO: Mosby Inc. Davidson, J. R. (2-4-2008). What is the Difference Between CPAP and BIPAP Ventilation? Retrieved February 5, 2009, from http://ezinearticles.com/?What-is-the-Difference-Between-CPAP-and-BIPAP-Ventilation?&id=965994&opt=print

47. References Kallet, R.H., & Diaz, J.V. (2009). The Physiologic Effects of Noninvasive Ventilation. Respiratory Care, 54(1) 102-114. Kilkenny, L.A., Fernandes, K.S., & Strollo, P.J., Jr. (2003). Disorders of Sleep. In R.L. Wilkins, J.K. Stoller, & C.L. Scanlan (Eds.), Egan's Fundamentals of Respiratory Care (8th ed., pp. 596-598). St. Louis, MO: Inc.-Mosby. Non-Invasive Positive Pressure Respiratory Assist Devices (BiPAP®). (12/07/2006). Retrieved February 1, 2009, from http://www.healthlink.com/provider/medpolicy/policies/guidelines/DME/bipap.html Pierson, D.J. (2009). History and Epidemiology of Noninvasive Ventilation in the Acute-care Setting. Respiratory Care, 54(1), 40-52. RespironicsBiPAP S/T User Manual. (1-4-2008). Retrieved January 29, 2009, from http://global.respironics.com/UserGuides/BiPAP_ST_User_Manual.pdf