BiPAP and DNR

[seinfeld]

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1. IF pt is a DNR/DNI should you use NIPPV

2. Give me a number. The number of hours one can be on BIPAP before its considered full , sustained mechanical ventilator support.

 

[Prof Moriarty]

1. IF pt is a DNR/DNI should you use NIPPV

2. Give me a number. The number of hours one can be on BIPAP before its considered full , sustained mechanical ventilator support.

1. DNR/DNI does not mean DNNIPPV. If it's medically warranted and can serve as a bridge through an acute episode, it seems reasonable to present as a treatment option.

I pulled this from an abstract in Critical Care Medicine:

Crit Care Med. 2004 Oct;32(10):2002-7.
Outcomes of patients with do-not-intubate orders treated with noninvasive ventilation.
Levy M, Tanios MA, Nelson D, Short K, Senechia A, Vespia J, Hill NS.
Division of Pulmonary, Critical Care and Sleep Medicine, Rhode Island Hospital, USA.
CONCLUSION: Patients with respiratory failure and a DNI status have a high overall mortality rate when treated with NPPV, but those with diagnoses such as congestive heart failure or chronic obstructive pulmonary disease, who have a strong cough, or who are awake have better prognoses. These data should be useful when counseling DNI patients and their families on use of NPPV.

2. Interesting question. BIPAP's not designed for long-term use right? How long would it take before the skin would start to break down under the mask? From what I've seen, about 2 weeks. By 3-4 weeks it could become intolerable.

Caveat: I'm a student with limited experience. What do you think?

 

[poresofkohn]

1. IF pt is a DNR/DNI should you use NIPPV

2. Give me a number. The number of hours one can be on BIPAP before its considered full , sustained mechanical ventilator support.

>
1) We routinley use NIPPV on DNR/DNI Pt's, usually at the families request. I've also used it many times to "buy some time" while a family member is on the way to say goodby. Whether we should or shouldn't is a different argument altogether I suppose.

2) Never. NIPPV is contraindicated in the apneic Pt. We use the Vision BiPAP machines here, and the "set rate" is just a backup rate. The Pt should always be breathing spontaneously on NIPPV.

 

[Bertelman]

1. IF pt is a DNR/DNI should you use NIPPV

2. Give me a number. The number of hours one can be on BIPAP before its considered full , sustained mechanical ventilator support.

1) DNR/DNI is in the eyes of the beholder. It's misused probably every day in every hospital, typically by nursing staff. If you suspect your patient who does not want to be intubated may indeed benefit from ventilatory support such as NIPPV, you should clear that from the patient or POA before slapping on a mask and positive pressure.

2) There is no such number. Define what you think "full mechanical ventilator support really is.

 

[cchoukal]

I'm an ICU fellow and this comes up from time to time. I don't consider the use of NIPPV a violation of a DNI request, but when I'm talking about "goals of care" and "code status" with patients, I mention NIPPV as one option on a continuum of respiratory support and give them the option.

Some people's reason for being DNI is not wanting to be in a position of discomfort and inability to communicate w/ family and eat, all of which are largely as true w/ NIPPV as with intubation. These people will likely decline NIPPV. However, if their problem is something likely temporary and reversible (flash pulmonary edema, TRALI, etc), I'll try to guide them to accept it.

For others, the DNI stems from a desire not to have a painful, invasive procedure or to be on "life support," and these people will usually accept NIPPV.

Anyway, in short, I don't think NIPPV violates a DNI and, when possible, I include it in the discussion of respiratory support options so they can decide for themselves.

 

[fakin' the funk]

Some people's reason for being DNI is not wanting to be in a position of discomfort and inability to communicate w/ family and eat, all of which are largely as true w/ NIPPV as with intubation. These people will likely decline NIPPV. However, if their problem is something likely temporary and reversible (flash pulmonary edema, TRALI, etc), I'll try to guide them to accept it.

I agree with you here. It is pretty much up to the physician to decide when to offer NIPPV to DNI patients. For some, it is appropriate (the acute, reversible things you mentioned) ... but when granny is so deconditioned she can't even ventilate, and is DNI, then in that situation trying to distinguish between IPPV and NIPPV is just wankery