Respiratory Therapy: EPAP and NIV Overview

Expiratory Positive Airway Pressure (EPAP)

• EPAP is airway pressure above 0cm H2O during the expiratory phase of breathing.
• EPAP is used in NIV for patients experiencing acute respiratory impairment.
• A tight seal must be maintained between the mask or prongs and the patient’s skin for EPAP to work effectively.
• Supplemental oxygen is required if it is ordered for the patient.

Non-invasive Ventilation (NIV)

• Primary treatment for OSA, a sleep disorder characterized by partial or complete airway obstruction
• 2 main forms are CPAP (Continuous Positive Airway Pressure) and NIVPP (Non-Invasive Positive Pressure Ventilation) – NIVPP uses a ventilator that cycles between inspiratory and expiratory phases.
• Used in the inpatient setting for patients who are experiencing acute respiratory impairment and, continuously as part of in-home care for patients with respiratory impairment.
• Also used at home for patients who have OSA.
• NIV is NOT for UNSTABLE and CRITICALLY ILL patients.

Indications For NIV

• Severe dyspnea
• Congestive heart failure
• Obstructive Sleep Apnea (OSA)
• Pulmonary edema
• Acute respiratory failure
• COPD

Obstructive Sleep Apnea (OSA)

• A condition where the patient has 5 episodes of apnea that last at least 10 seconds each within one-hour time period while asleep.

Contraindications for NIV

• Apnea
• Hypoventilation

Tracheal Tube Confirmation

• **Re-confirm the tube mark at the front teeth. **
• Insert an OPA (Oropharyngeal Airway)
• Dry the patient’s face and apply tincture of benzoin
• **Carry the tape right around the patient’s neck when anchoring the tube. **
• Anchor the tube at the corner of the mouth, not in the midline.
• Look for MOISTURE CONDENSATION on the inside of the tracheal tube with exhalation

Secondary Confirmation

• End-Tidal CO2 detector device - The device reacts with a color change to exhaled CO2 from the lungs. Absence of CO2 response from the detector generally means that the tube is in the esophagus.

Complications of Mechanical Ventilation

• Barotrauma - Injury to the lungs or other air-filled spaces caused by changes in pressure, often due to mechanical ventilation
• Volutrauma – Lung injury resulting from over-distension of alveoli due to excessive tidal volumes during mechanical ventilation

Nursing Considerations for Mechanical Ventilation

• Maintain urinary and bowel elimination
• Maintain eye, mouth, and skin cleanliness and integrity
• Maintain mobility/ musculoskeletal function
• Provide psychological support
• Monitor for:
  • PaO2 80-100mmHg
  • Effective breathing patterns
  • Hemodynamic stability
  • Increased/stable hemoglobin
  • Adequate tissue perfusion
  • UO >30cc/hr

Acute Gastrointestinal Bleeding

• Peptic ulcer disease, etc.
• Assess
• History of liver disease, alcohol use.
• Checking for signs of bleeding, such as tachycardia, hypotension.
• Determine location, nature, and resolution of the bleeding.
• Endoscopy, PPI, surgical consult
• Prevention of recurrent bleeding
  • Gastric acid suppression
  • Minimize precipitating factors

Nursing Considerations for Acute GI Bleed

• Maintain breathing patterns
• Provide comfort and safety
• Lessen anxiety
• Prevention of complications

Acute Pancreatitis

• Caused by gallstones or excessive alcohol consumption.
• Pathophysiology: Autodigestion
• Mild: Edematous/interstitial
• Moderately Severe: Hypovolemia, pain, organ failure.
• Severe: Necrotizing.
• Gallstone pancreatitis: Perform ERCP

Nursing Considerations for Acute Pancreatitis

• Oxygen supplementation
• Pain management
• Fluid resuscitation
• Prevent and treat infection
• Prevent complications
• Surgery

Esophageal Varices

• Swollen veins in the lower esophagus
• Occurs due to increased pressure in the portal vein
• Often resulting from liver cirrhosis.
• Can rupture and cause severe bleeding

Nursing Considerations for Esophageal Varices

• Assess history of liver disease, alcohol use, and previous variceal bleeding.
• Check for signs of liver disease
• Check for signs of bleeding, such as melena, hematemesis.

Diabetic Ketoacidosis (DKA)

• Acute complication of DM.
• Results from severe insulin deficiency.
• Has a sudden onset.

Etiology of DKA

• Typically caused by undiagnosed diabetes or the inadequacy of the prescribed therapy.

Clinical Manifestations of DKA

• Blood sugar levels greater than 300 mg/dL
• Serum pH less than 7.35
• Elevated ketone levels
• Sweet, fruity breath

Hyperosmolar Hyperglycemic Nonketotic State (HHNS)

• Severe hyperglycemia; usually greater than 600 mg/dL
• pH less than 7.4
• Ketones – negative
• Profound dehydration
• Altered level of consciousness

Interprofessional Care for DKA

• Aggressive intravenous rehydration with normal saline or Lactated Ringers
• Lowering of the blood sugar with a short-acting insulin, such as regular insulin given through continuous intravenous infusion.
• When blood sugar levels fall below 250 mg/dL, the IV solution should be changed to a dextrose-containing solution, e.g., 0.9% NaCl/5% dextrose.

Management of DM

• Diet - Regular meal schedule including snacks
• Exercise - recommendation 3 times a week
• Insulin - for Type 1 DM
• Oral Hypoglycemic Agents (OHA) - for Type 2 DM