Charlotte Burns, SRTRobyn Borkowski, SRT

Kimberly Sizemore, SRTShawn Thomas, SRT

Claire Washington, SRT

Support and equipment was provided by Lone Star- Kingwood College

Respiratory Dept.

We hypothesize that patient positioning does in fact play a vital role in the

delivery of tidal volumes during bi-level positive airway pressure.

Will changes in body position affect the return VT on a healthy adult getting

BiPAP?

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.

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.

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).

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.

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.

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)

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)

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.

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

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

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).

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 pathophysiological process 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.

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.

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

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.

Guillain Barre-is an acute inflammatory demyelinating polyneuropathy (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

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

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.

Oxygen saturation (SO2), commonly abbreviated as "sats", measures the percentage of hemoglobin binding sites in the bloodstream occupied by oxygen

PaCO, n partial pressure of carbon dioxide in the blood. Critical in regulating breathing levels and maintaining body pH

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 se t 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

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).

Subjects were gathered from Lone Star Community College Kingwood

We had informed consent forms signed and witnessed.

Test subjects were given detailed written instruction

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

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

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.

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.

Previous slide had all original data from the 3 positions that the subjects were in and the Tidal Volumes they produced.

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

Caucasian

African American

Asian Hispanic

C1 X

C2 X

C3 X

C4 X

C5 X

C6 X

C7 X

C8 X

C9 X

C10 X

C11 X

C12 X

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

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

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

Left Handed Right Handed

C1 X

C2 X

C3 X

C4 X

C5 X

C6 X

C7 X

C8 X

C9 X

C10 X

C11 X

C12 X

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

Average Vt for a left handed person in supine position=709

Average Vt for a left handed person insemi-fowler position=853

Average Vt for a left handed person in high-fowler position=824

% change in Supine VS High fowler

% change in Semifowler Vs

% change in Supine VS High fowler

-2.649 8.89423 6.00961

0.199601 10.8407 10.8407

-0.53475 -2.77296 -3.29289

-8.16326 1.47928 -6.80473

-7.28862 -0.72358 -7.95947

-0.15723 -6.47058 -6.61764

-5.7377 8.51334 3.47043

-0.11299 4.77001 3.05429

17.58793 -10.8623 4.81522

-16.8816 1.33495 -13.9563

3.81303 16.50853 3.43137

-7.65472 16.50854 7.59013

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

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.

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

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

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.

(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

 

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.

 Respironics BiPAP S/T User Manual. (1-4-2008). Retrieved January 29, 2009, from http://global.respironics.com/UserGuides/BiPAP_ST_User_Manual.pdf