NONINVASIVE VENTILATOR SETUP

These competencies are protected by United States Copyright 1999 - 2005 and the clinical database system is Patent Pending to UTMB (University of Texas Medical Branch at Galveston)

[Brackets denote competency modification] Asterisk* denotes a Safety EQUIPMENT AND PATIENT PREPARATION 1. *Verifies physician's order for appropriateness or evaluates procedure based on hospital policy (indicated for: short term ventilation for patients with acute or chronic respiratory failure or CHF; patients who develop post extubation difficulty; long term assistance for patients with disorders of the chest wall or neuromuscular system or obstructive sleep apnea)(ref. 1, 2) 2. *Reviews patient chart for significant findings and data 3. *Identifies and gathers the necessary equipment (ventilator, circuit, oxygen adaptor and accessories) 4. *Select appropriate size nasal or face mask, using manufacturers guidelines and templates (Note select the smallest size mask that comfortably fits the patient) (ref. 3) 5. *Applies 3 or more mL of an alcohol-based hand rub to palm and rub hands together covering all surfaces of each hand until hands are dry (Caution: should take at least 15 seconds for hands to become dry); or if hands are visibly dirty or contaminated perform hand wash using a vigorous rubbing action for at least [15] seconds; and uses appropriate isolation precautions (CDC-ref. 4) [PUTS ON GLOVES] 6. *Introduces self to the patient, stating name, department; confirms patient identification. 7. *Explains the purpose of the procedure, including risks and safety precautions 8. Confirms patient and/or family understanding of the procedure IMPLEMENTATION OF PROCEDURE 1. *Connects ventilator to electrical source with generator backup 2. *Assembles circuit; add oxygen as appropriate; and confirms integrity of the system 3. *Performs ventilator operational verification procedure and confirms proper function (ref. 5) 4. *[Using manufacturers recommendations, selects appropriate nasal or full face mask for patient.] 5. *Select mode of ventilation based on physician order or protocol and set IPAP, EPAP, Rate, and I:E ratio, etc. as appropriate. [Preset appropriate alarms] 6. [Connect NIPPV device to patient mask, cycle the mode on, and allow patient to feel flow against cheek] 7. *Fit interface to patient using appropriate spacers and head gear (Caution: do not overtighten mask, masks are designed to be comfortably fitted) (ref. 3) [Instruct patient to keep mouth closed if using a nasal mask or pillows. Verifies amount of leak is acceptable.] 8. *Adjust expiratory pressure (EPAP). Use initial setting of 2-5 cmH2O based on device being used; adjust EPAP in small increments (2-5 cmH2O) to desired level based on clinical indicators (e.g. increase FRC and improve oxygenation in patients with decreased compliance or shunting; decrease use of accessory muscles for patients with intrinsic PEEP; manage upper airway obstruction in OSA) (ref. 1) 9. *Adjust inspiratory pressure (IPAP) initially 35 cmH2O above EPAP; increase IPAP in 2 cmH2O increments to desired level based on clinical indicators (e.g. stabilize PaCO2, relieve dyspnea, or reduce the use of accessory muscles (ref. 6) 10. *Adjust oxygen [percentage] or liter flow to maintain clinically acceptable oxygen tension (if applicable) 11. *Check for proper mask fit and correct leak if necessary 12. *Adjusts alarms depending on monitoring device 13. Advise patient to notify personnel if chest discomfort, shortness of breath, or severe headache occur during use of NIPPV (ref. 6)

EVALUATION & MONITORING 14. Establish base line NIPPV monitoring information and record data on flow sheet 15. Evaluates pulse, blood pressure, respiratory rate, and saturation for appropriateness 16. Evaluates ABG and suggest appropriate changes to pressure settings or oxygenation 17. Periodically evaluate chest X-ray for development of barotraumas 18. Completes breaths sounds evaluation FOLLOW-UP 19. Decontaminates hands with an alcohol-based hand rub or performs a 15 second hand wash 20. Records relevant data in patient chart and appropriate departmental records 21. Provides suggestions for modification of the patient care plan to physician or appropriate personnel, or modifies patient care plan following appropriate protocol DEMONSTRATES KNOWLEDGE OF FUNDAMENTAL CONCEPTS (ref. 1, 6) 1. Identifies three indications and three complications for NIPPV 2. Identify five patients in which NIPPV would be contraindicated (ref. 1) 3. Identify three advantages of NIPPV over conventional mechanical ventilation 4. Explain why over tightening of the mask should be avoided (ref. 6) 5. Identify the trigger and cycling function associated with the different modes CLINICAL COMPETENCY PERFORMANCE CRITERIA 1. Displays rational judgment and is able to explain the relationship between theory and clinical practice. 2. Performs procedure in a reasonable time frame and with attention to appropriate detail 3. Maintains aseptic technique and takes appropriate safety precautions 4. Communicates clearly, and in a courteous manner REQUIRED: Summary Performance Evaluation Please use the following criteria and select the appropriate pop-up menu. Satisfactory - ready for clinical application with minimal supervision. Performed procedure accurately, or was able to correct performance without injury to the patient or decreasing effect of therapy being given. [Unsatisfactory performance not ready for clinical application. Requires remediation and complete reevaluation of the procedure.] References: (use most recent editions) 1. Pilbeam SP: Mechanical Ventilation Physiological and Clinical Applications. Mosby 3rd, 1998.Equipment 2. Scanlan CL, Spearman CB, Sheldon RL: "Egan's Fundamentals of Respiratory Care Mosby 7th, 1999, Ch. 40 3. Respironics Inc. Masks & Accessories: An Examination of Size, Fit and Adjustments. 1993. 4. CDC, Guideline for Hand Hygiene in Healthcare Settings. MMWR Oct. 25, 2002; vol. 51(No. RR-16) 5. AARC Clinical Practice Guideline: Patient-Ventilator System Checks RC 1992;37: p882-886 6. Respironics Inc. Suggested Protocol for Initiation of the BiPAP S/T-D Ventilatory Support System. 1993 7. For additional information on the BiPAP system visit:
www.healthcare.philips.com/main/homehealth/respironics.wpd

Clinical Practice Set-ups:

Instructor Signature 1._________________________ 2._________________________ 3._________________________

Date ___________ ___________ ___________

Additional Comments: include errors of oversight or sequence, strengths and weaknesses during procedure (i.e. knowledge, communication skills, and patient interaction skills)

Summative Performance Evaluation: NIV Satisfactory ______ Minor Unsatisfactory ______ Major Unsatisfactory ______ ___________________________________ Name of person being evaluated ___________________________________ Signature of Direct Supervisor _______________ Date _________ Grade