im not a doctor and even my english not that good i want to tell you this video helps me to much as my father has copd and its very simple to understand, Keep going god bless you.
This video is a dynamite! Bro this is an epic video. U brought somuch clarity in such a short span of time ... will remember as long as i see am ABG .... thanks bro!
Fantastic videos! As an RT for many years about to re-enter the work force after caring for mom the last couple of years, I find the material and extremely pleasant teaching manner wonderful. Thanks for this!!
@@RespiratoryCoach Thank you! I am binge watching your videos. So much to learn! You explain eveything so well. It’s just incredible. You are appreciated. Blessings to you and your family.🙏🏾
Omg. I’m in my second term of RT school and I was just so lost when trying to learn about this portion of noninvasive ventilation. Thank you so much for making your videos!
How would you know how much to go up when you make adjustments? Like when you went up by 5 and by 4 on your IPAP and EPAP to address oxygenation problem but keeping your PS the same.
Hi Joanne. First, thanks for watching and posting your question. An oxygenation problem would be a patient who's PaO2 is below normal, say 54. Or might be indicated by a low saturation, say 84%. You might also say a patient had an oxygenation problem if their PaO2 was 80, but they were requiring 80% oxygen to achieve that. A ventilation problem would best be illustrated by a patient with a high CO2 (65) and a low pH (7.15), or a patient with a normal CO2 and pH, but is requiring 12lpm of minute volume to achieve that normal gas. Does that help clarify? Let me know if not.
@@RespiratoryCoach Yes, but I was wondering how you would adjust the settings for the IPAP & EPAP if there was an oxygenation and ventilation problem. Let say a patient who has a CO2 rate of 31 and is moderately hypoxemic?
I see, Joanne. So if your CO2 is 31, which means it's low, then you need to decrease the difference between IPAP and EPAP, which you could easily do by increasing EPAP to address the moderate hypoxemia. So if the patient was on 12/5, then increasing the EPAP to 8, would now put them on 12/8. Your pressure support is lower thus your CO2 should return to normal, and with the added EPAP hopefully your hypoxemia will correct. Let's say your patient was on 10/5 and their ABG came back with a high CO2 and a low O2. Then to address the low oxygen we would increase EPAP, let's say to 8. To address the high CO2 we need to increase the PS, which we know is the difference between IPAP and EPAP. If we placed IPAP on 13, we would do nothing for the high CO2 because the difference is still 5. So we would need to increase the IPAP to 15 or 18, now our PS is 7-10, which is an increase from 5 and our CO2 should come down. Does that answer your question?
This is wonderful! THANK YOU! I was pausing the video after the first example, and I got it right each time. This will be in my lab final, so thank you again for doing this!
Very good appreciate ur work, can u pls make video on oxygen therapy, which mode of oxygenation should be used in which setting,when to use high flow system when to use low flow system, when to use Nasal canula,face mask,high flow nasal canula,NRBM etc.
I don't have enough information to answer. Doesn't look like any Ipap is needed. Maybe airvo for the hypoxemia? Co2 is 25? Why are they hyperventilating?
@@RespiratoryCoach he is covid patient and suffering from pneumonia...he is on bipap from last 5 days...at 16 and 8 settings... His spo2 87 above... .. condition in India is really bad these days..
Hi Joe. I have a question. regard to TMC exam . Do we have to increase EPAP and IPAP to maintain the same pressure support and keep pH and CO2 at previous levels? I am super confused
Hello Viv! Yes, those are good "guidelines" to operate within, but not concrete boundaries. Good question! Thanks for watching and asking your questions.
Okay got it oxygenation problem increase epap and keep the pressure support so increase IPap as well. If the problem is ventilation then increase IPAP alone.
Hey, Tim! Essentially yes, but there is one potential scenario to consider. Let's say a patient is placed on 15/10, but has no oxygenation issues. In this case, we could leave IPAP at 15 and decrease EPAP to 5, and that would increase PS without having to increase IPAP. Just wanted to throw that out there. Thanks for commenting and watching. Good luck on your upcoming CSE!!!
Omg.....this made so much sense to me.....ugh.....thank you soo much for the service you provide selflessly...studying is hard for some of us without examples. Thank you!!!!!😘😘😘😘😘
Hey Coach, before watching the video I thought that IPAP removed the CO2(or maintained ventilation). If pressure support is driving the CO2 removal, then what does the IPAP pressure do? I know that IPAP-EPAP = pressure support and that EPAP is on expiration.
Updated video coming out soon to address this question, but the quick answer is to establish your necessary PS via IPAP (for ventilation), and then increase EPAP (oxygenation) while maintaining that same pressure difference, which is PS. Stay tuned!
What if we had oxygenation and ventilation problem such as iPap 18 Epap 8 ph 7.51 paco2 30 pao2 55 hco3 25 , would you fix o2 so if I increase epap 12 for oxygenation decrease ps to 6 decreasing vt would increase paco2 and decrease ph. This makes so much more sense thank you so much
Ok so of topic but I get confused when there’s mixed issues in mechanical vent say the ot was sedated vc ph 7.15 paco2 65 pao2 of 45 and hco3 18 fio2 of 60% and peep of 5? NBRC says fix oxygenation first so I would either increase fio2 first or increase peep 7 then fix ventilation ? Like what’s more correct answer because if these kinds of scenarios are on boards I’m like which they pick both fix oxygenation but one has sever consequences on cardiac output, lowering henodynamics of a Pt ?
You're exactly right. By increasing epap alone, you will address your hypoxemia, but also will decrease the difference between IPAP and EPAP, thus decreasing the PS, which will help to correct the hyperventilation.
Hey Sagar, you should fix ventilation first, EXCEPT when you have a patient that is hyperventilating due to hypoxemia. In that case, fix the oxygen first. To your scenario, you would first fix co2 and then address o2. Since you are already on 60%, your next move is to increase peep until cardiac side effects are observed. At that point return peep to the level with stable hemodynamics, and increase fio2. Hope this makes sense and clears things up. Thank you for watching and commenting with your scenarios. I like them.
Respiratory Coach wow that was such a dumb question for me ask ,I just had think about it if they are hyperventilating obviously you wouldn’t fix ventilation first , because they are already over ventilating the best modification would be oxygenation to correct for hypoxemia which is why they may or maybe not be hyperventilating if it’s something is not going on in the body.
Hello there! Your video is amazing and simplifies it all so it’s much easier to understand. Thank you! My question is on the actual state board tests it asks questions about changing the settings but they give answers like changing minute ventilation and such. It’s never as easy as you explain it. I feel like it goes into way more detail. It’s like they take it a step further in depth. Can you be owing this pretty please!!!
Good feedback. This was one of my very first videos and directed to a group of students who understood the lingo. I see where you are coming from though. Thank you!!
Hey Coach, if the patient only has a oxygenation problem, should we just place the patient on a HFNC? If ventilation isn't the issue, why keep the patient on a V60 with the complication risks that comes with it? To some extent, HFNC washes out some deadspace and can remove some CO2; jus not as well as BiPAP on V60. Claustrophobia, pressure sores, aspiration risk, speech/communication etc can prevented. Just a thought.
I agree with you! The rise of HFNC has most definitely lead to the decline of NIV for oxygenation issues. The only thing I will add is that HFNC is less effective in establishing PEEP, so in acute CHF or a large shunt, effective PEEP levels are desirable to maximize P/F ratio. But yes, you make a great point when it comes to pure oxygenation issues.
Thank you very much.... Frequently I face difficulty regarding proper sized mask during NPPV resulting in moderate leakage. How can i solve this issue?
Hello, Jayanta. You're very welcome. Correct mask sizing is definitely the key to successful NIV. For those patients in between mask sizes, I will try both masks to see which one yields the smallest leak. This usually results in greater patient comfort and tolerance. The biggest mistake commonly made is trying to fix the leak by making the mask tighter. That rarely works and usually worsens the leak and patient comfort. Hope this helps a little. Thank you for watching and posting your question.
A bundle of thx for the simplified and comprehensive explanations. Sometime we come across patients with type 2 respiratory failure having high CO2 levels and low Oxygen concentrations. e.g 7.21/68/46/16/73% Although such critical patients do need intubation but still if we can't intubate them then what will be the best settings for BIPAP.
Hi, Saeed! For that gas you provided, if I were going to attempt NIV first (probably wouldn't, but let's just go with it)I would be aggressive with my EPAP setting to maximize oxygenation, as well as an aggressive IPAP setting to maximize ventilation. So IPAP 20 / EPAP 10. Watch my return tidal volume, minute ventilation, patient presentation, Sp02, reassess a gas in 30 minutes and hope for an improvement. If those settings don't show improvement fairly quickly, this patient needs to be intubated. Hey, thanks for watching and offering this example!
This is a challenging question because what may be excessive for one patient, may not be for another. Also, there's no defined absolute high limit for IPAP. Close patient assessment and monitoring is your best friend in avoiding lung injury.
Because EPEP increases FRC, like PEEP, it increases surface area and decreases AC membrane thickness. This allows for more oxygen to diffusion into arterial blood.
My husband just did his sleep test. He's waited 2 months. And now has to wait another 2 for a Dr appointment. I've purchased everything he needs and somewhat understand how to use it. I'm just not sure about the setting I was told. The therapist that read his results said he needs a automatic CPAP set at 14-16. He had covid and blood clots. That have went away. But the inflammation is still around his air ways, causing mild blockage. He's been off of oxygen for 3 months not and keeps his oxygen saturation at good levels unless he's moving ALOT, and during sleep. He's not a high risk, but worrisome. Can you please tell me what might be best? Where do I start? I've watched a ton of videos, and know how to adjust. My machine is a CPAP, bipap, or vpap
It would be irresponsible for me or anyone to offer medical guidance from a far in this situation. I recommend calling your provider for instructions or immediate guidance. The home health company where you got the bipap would be a good resource as well, since they will be operating within ordered settings.
Absolutely you can, but it depends on the total rate. If the patient is breathing greater than the set rate, then decreasing the rate will have no impact.
Great work, but how does the situation change when FiO2 factor comes in. case in point a normocapnic hypoxemic patient, should i increase fio2 or epap. much thanks
Such a great and easy way to understand NPPV. THANK YOU! Im in my second semester of RT school and I feel like i hit a jackpot coming across your videos ✨✨✨✨
Hi, I was wondering if you can put some patient assessment ( case studies ) , I am a respiratory students, I have hard time with it thank you so much, for all your efforts 👍😊😊👍👍👍
Hey ..great video.. really helpful.. i have a question though.. what if The Co2, O2 and Bicarbonate are way below normal with a Normal Ph. What do we do then?
Hypoxic-👍EPAP & PS same 👎CO2 👎PS & EPAP same 👍CO2 👍PS & EPAP same Coach have I correctly understood ? Another question now how do we get the initial setting of IPAP& EPAP ? How much can we increase or decrease these parameters ? Also guidelines to set the RR ? What is ST mode in Bipap ? Sorry no arrow signs on my page so used thumb signs to show increase and decrease..
Max IPAP will vary per patient. There is no one stated "max" IPAP for all patients. It all depends on the patient's response to NIV therapy and ABG values. Thanks for watching, Jay!
Why use BiPAP if it is purely an oxygenation problem? I was taught that if it's an oxygenation problem only, we would use high flow. BiPAP is only for ventilation to blow off CO2. Just a suggestion - it would help to know what the normal baseline settings are for biPAP initiation and what the maximum settings are (and what scenarios we would use the maximum settings).
I feel like we kept FiO2 out of the conversation, in regards to oxygenation. If the patient feels comfortable with the support settings, yet values show oxygenation issues, you can keep the support settings while supplementing oxygen by way of FiO2.
On the v60 at my facility we also set o2%. So if there's an oxygenation issue and say we only increase the o2% and not the epap. What will be the result? Will it eventually lead to further problems or is it just fine?
That's correct. Pretty much every ventilator available also has a set FiO2. You can increase FiO2, but in the presence of a shunt, only increasing EPAP will truly improve the efficiency of oxygenation. The result will probably be a large increase in FiO2 with a small improvement in your PaO2, a terrible P/F ratio, and an enormous A-a difference. To prevent hazards of oxygen therapy, as experts, we should be the ones that emphasize achieving acceptable oxygenation for our patients, while reducing the risk of oxygen toxicity and absorption atelectasis. Utilizing EPAP, CPAP, EPAP allows us to achieve desired oxygenation with lower FiO2s, which results in better P/F ratios, smaller A-a's, and less risk of those above mentioned hazards of oxygen therapy. Thanks for asking McClinton!!
@@RespiratoryCoach great explanation Joe.I feel that I'm not always critically thinking and sometimes just find myself doing what the physicians order. Now being in the work field versus being a student, I want to provide the best care I can for my pt since I'm an advocate for them. Keep these videos coming,we need them. I should have paid better attention in school 🤷🏾♀️🤦🏾♀️
@@mcclintonthomas Hey McClinton, don't sweat it, many recent graduates deal with the same struggles. This is you going from being new to becoming your own respiratory therapist. I've heard good things about the work you're doing. Keep it up and NEVER stop learning. Best wishes!!
@@RespiratoryCoach thanks, can we get a small talk about ABG vs VBG and correlations between the 2. I know po2 isn't accurate but would love to hear more from the coach
Ideally the patient is spontaneously breathing so control of I:E isn't really a part of the equation because it's outside of our control. Thanks for watching and commenting with a great question!
Increase the pressure gradient between IPAP and EPAP (PS) and titrate fio2 accordingly, but reducing that CO2 should be the primary focus in this scenario. Thanks for the question and for watching.
thank you coach. i have one question some books say escalate ipap by only 2cmh2o and epap 1cmh2o but in your discussion you escalate ipap by five can we do that?
No problem, Prince. Thank you for watching. I'm not aware of any hard set rules related to increasing IPAP. I typically stay around the 3-5 cwp range per change, mostly for patient comfort. You start making massive increases in IPAP, your patient probably isn't going to tolerate very well. Once I get to 20-22cwp of IPAP, if that's not working for my patient, then NIV is probably not the answer. Hope that answered your question and helps as a general guideline.
