PROTOCOL- EMERGENT/ RESPIRATORY FAILURE BIPAP

Director _________________

Medical Director _________________

PURPOSE: To provide instructions for the initiation and maintenance of BiPAP

therapy on patients in the emergency setting. Therapy will be delivered by a licensed
Respiratory Care Practitioner who has completed the competency for BiPAP use. The
emergent BiPAP protocol has been developed and approved by the appropriate medical
care staff, directors, and hospital committees. 

POLICY: 

A. Respiratory Care Practitioner (RCP) will evaluate patient for appropriateness or any
contraindications for emergent BiPAP protocol
B. Emergent BiPAP protocol will be written, signed and dated by physician
C. RCP will initiate Bipap and monitor effectiveness and hemodynamics of patient
D. Patient will be closely monitored in the ICU, emergency department, or step down ICU
E. Frequency of documentation will every hour in the acute setting, and every 2 hours when
patient is stable
F. Arterial Blood Gas (ABG) will be obtained after 30 min of initial BiPAP therapy
G. RCP will make any necessary changes to Bipap settings based on ABG results and patient
compliance
H. The RCP will work and communicate with both physician and nurse on BiPAP therapy
effectiveness and patient progress
I. If clinical status and gas exchange does not improve the RCP will consider intubation 

MODALITIES: 

A. Modalities included in BiPAP initiation protocol are:

a. Bronchodilator therapy - treatments should be given in nebulized form through the
BiPAP to limit interruptions in non-invasive ventilation 
b. Oxygen therapy/ SpO2 Monitoring - oxygen will be provided through the BiPAP to
limit interruptions in non-invasive ventilation 
B. Medications and Oxygen
a. Oxygen and bronchodilators will be provided through the BiPAP 
b. Medication, indications and suggested dosage/ frequency included under respiratory
therapy protocols 
c. Inhaled medications including corticosteroids or other maintenance medications may
be added as per home use
 LIMITATIONS (if not a home medication these require a physician order)
 Long Acting Bronchodilators
 Corticosteroids
d. Some medications may be placed on hold or given via IV access to prevent breaks in
therapeutic non-invasive ventilation via BIPAP

INTERACTIONS:
A. Physician interactions - Respiratory Therapy will notify the Physician if: 
 Adverse response is noted
 Acute change in mentation
 Significant increase in oxygen requirements
 Lack of response to therapeutic measure
 Worsening ventilation status
B. Nursing interactions-Respiratory Therapy will notify the RN/ LPN if: 
 Adverse reactions are noted
 When oxygen requirements change
 Any acute changes in patient’s condition
 Any complaints of pain or other patient needs

PROCEDURE: 

A. Select an appropriate type and size of mask

 Adjust mask for patient comfort and to avoid pressure points
 Adjust mask until a leak of 10-30 L/min is achieved
B. Initial BiPAP settings 
 IPAP: 10 cmH2O
 EPAP: 5 cmH2O
 Backup rate: 8 BPM
 FiO2: to achieve an SPO2 of 90% or above
C. Adjust IPAP by increments of 2 cmH2O until a desired tidal volume of 6-8ml/kg is
achieved
D. If an FiO2 of 60% does not achieve SpO2 goals, adjust EPAP by increments of 2 cmH2O
until an SpO2 of 90% or above is obtained 
E. Obtain an ABG after 30 min of BiPAP therapy, and based on results make appropriate
changes in settings
 Adjust IPAP by increments of 2 cmH2O to achieve a PH of 7.35-7.45
 Adjust EPAP by increments of 2 cmH2O or FiO2 by increments of 5% to achieve
an PaO2 of 60 mmHg or above
F. If clinical status of patient and gas exchange has not improved within 1 to 2 hours;
consider intubation
G. Consider heated humidity to prevent dried secretions in the oropharynx or for periods of
time BiPAP therapy >24hours 

QUALIFICATION AND PATIENT ASSESSMENT:

 A. Physical Assessment, including but not limited to:
a. Appearance
b. Heart Rate, respiratory rate
c. Chest inspection, palpation, percussion, auscultation
d. SpO2
e. WOB, SOB
f. Apparent hypoxia 
g. Acute hypercarbia
B. Evaluation for therapy:
a. Evaluate for appropriate therapy as supported by AARC Clinical Practice
Guidelines, and the methods outlined in respective therapy algorithms that
coincide with appropriate policy and procedure
i. Patient must be easily arousable
ii. Patient must receive education and demonstrate understanding regarding
conditions when the mask should be emergently removed ie: vomiting 
iii. Patient must be physically able to remove the mask
b. Establish patient respiratory history and compliance with home medications and
therapies
c. Provide patients with education/ instructions regarding BiPAP
d. Diagnostic ABG’s, SpO2, chest x-rays, labs (electrolytes, WBC, Hgb, Hct,
sputum culture, etc.) as pertains
e. Patients will be evaluated at least Q4 or whenever significant changes occur in
clinical status 
f. Inspect supplies and change as needed
g. Adjustments to BiPAP therapy should be initiated as needed, tolerated or
indicated by patient, diagnostic measures or as ordered by physician

DOCUMENTATION:
A. A care plan should be documented in electronic charting under the “Care Plan” tab. A
care plan should include relevant subjective and objective information and assessment
data to support the proposed treatment plan. 
B. Document protocol evaluation under “Non-invasive Therapy” tab through electronic
charting (or Respiratory Therapy paperwork when applicable)
a. Date and time of protocol initiation
b. Pertinent diagnostic results
c. Pertinent medical history 
d. cmH2O of IPAP and EPAP
e. FiO or Oxygen liter flow
2

f. Set respiratory rate/ actual respiratory rate

g. Rise time, inspiratory time, patient comfort features if appropriate
h. Mode
i. Estimated Tidal Volume
j. Estimated Leak
k. Alarm Settings
 l. Humifications water level and/ or humidifies temperature
m. Mask type/ size 
n. Device used to administer therapy
o. Assessment/ Vitals
i. Breath Sounds
ii. Cough/ sputum if applicable
iii. LOC
iv. Physical appearance ie: retractions, WOB, cyanosis, etc.
v. Heart Rate
vi. SpO2
C. Medications given through BiPAP will be documented under “Treatment” tab through
electronic charting (or Respiratory Therapy paperwork when applicable)
a. Medications included: 
i. Long term/ short term bronchodilators
ii. Other inhalation medications given through BiPAP
b. Vital signs before and after treatment should be charted
i. Breath sounds, cough/ sputum if applicable, LOC, physical appearance,
heart rate, SpO2
ii. Any acute worsening changes in vitals should be reported to nursing/
physician ie: increase or decrease in heart rate more than 20 bpm, increase
in WOB, increase in oxygen requirements, etc

INDICATIONS:
A. Impending or chronic ventilatory muscle fatigue
B. Cardiogenic pulmonary edema 
C. Post extubation difficulties and where reintubation can be avoided through non-invasive
positive pressure ventilation
D. Worsening hypoxemia despite the use of supplemental oxygen
E. Patients with worsening alveolar hyperventilation indicated by elevated or rising PaCO2
who do not have an artificial airway 
F. Palliative care for patients refusing intubation
G. Upper airway obstruction due to conditions like restriction of the extra thoracic trachea,
obstructive tracheal or glottic lesions in instances where invasive mechanical ventilation
is to be avoided, laryngeal, and supra or subglottic edema in the post extubation period

CONTRAINDICATION:

A. Untreated pneumothorax or cardiovascular instability

B. Facial burns, maxillofacial fractures, acute facial trauma
C. Epistaxis, upper GI bleed, or active hemoptysis
D. Excessive secretions, active vomiting, or untreated nausea
E. Patients with artificial airways
F. Increased intracranial pressure greater than 20 mmHg
G. Allergy or hypersensitivity to masks, unless additional protection is added
H. Inability to establish, maintain or protect the airway
 I. Combativeness, altered mental status, the need for chemical or physical restraints unless
the patient is in ICU and constantly monitored
J. Progressively compromised airways like a known difficult airway, inability to maintain
spontaneous ventilation

COMPLICATIONS/ HAZARDS:
A. Aspiration
B. Pneumonia 
C. Gastric distress 
D. Hypotension 
E. Pneumothorax 
F. Further weakening of respiratory muscles 
G. Air Leakage from poorly fitted mask

ADVERSE EFFECTS: 

A. Dry mouth
B. Nasal congestion
C. Rhinitis 
D. Claustrophobia 
E. General discomfort 
F. Skin irritation or damage  
G. Sinus pain
H. eye irritation 

INFECTION CONTROL: 

A. Universal precautions (unless other specified)

B. Proper PPE worn always
C. Bacterial filters utilized when appropriate/ available
D. Replacement of any soiled equipment
E. All disposable equipment should be new for each patient ie: masks, skin barriers, tubing,
filters, humidification devices, etc
F. Humidification devices will use sterile water only 
G. Wipe down of stethoscope after use
H. Utilize hand washing/ sanitizing before entering and after leaving patient’s room
I. All non-disposable medical equipment should have been disassembled to be sterilized/
received a high-level disinfection then reassembled and ready for use

EQUIPMENT:

A. Phillips Respironics V60 Ventilator

B. Respironics Patient Mask 
C. Bacteria Filter
D. Patient circuit
E. 50 PSI oxygen port
References:

Aerosol Therapy During Noninvasive Ventilation or ... - Breas.ru.breas.com/wp-

content/uploads/2014/10/Aerosol-Therapy-During-Noninvasive-Ventilation-

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ASA Authors & ReviewersSleep Physician at American Sleep Association Reviewers and

WritersBoard-certified sleep M.D. physicians, scientists, editors and writers for ASA.

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William A. Rutala, Ph.D., M.P.H.1,2, David J. Weber, M.D., M.P.H.1,2, and the Healthcare

Infection Control Practices Advisory Committee (HICPAC)3