From the Guidelines
Asynchronous breathing in BiPAP patients should be managed through informed adjustment of ventilator settings, including optimizing IPAP, EPAP, and rise time, as well as patient-centered interventions, to minimize patient-ventilator asynchrony and improve outcomes. This approach is supported by the BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults, which states that patient-ventilator asynchrony is common and deleterious, and can be minimized through informed adjustment of ventilator settings 1. The key to managing asynchronous breathing is to optimize the BiPAP settings to better match the patient's respiratory pattern, and to implement patient-centered interventions to improve comfort and reduce asynchrony.
Some key strategies for managing asynchronous breathing in BiPAP patients include:
- Optimizing IPAP, EPAP, and rise time to match the patient's respiratory pattern
- Increasing trigger sensitivity to make the machine more responsive to the patient's breathing efforts
- Adjusting inspiratory time or implementing a backup rate if the patient is consistently fighting the machine
- Ensuring proper mask fit to prevent leaks, which can trigger asynchrony
- Positioning the patient upright at 30-45 degrees to improve comfort and reduce asynchrony
- Using short-acting anxiolytics like lorazepam 0.5-1mg for agitated patients, but using cautiously to avoid respiratory depression
- Educating patients about breathing with the machine rather than against it, to improve synchrony and reduce asynchrony.
It's also important to note that proportional and NAVA have been shown experimentally to reduce ventilator asynchrony, but have yet to improve patient outcome 1. Additionally, the American Academy of Sleep Medicine has developed recommendations for the titration of NPPV in the sleep center, which include adjusting pressure settings, backup rate, and inspiratory time to maintain upper airway patency and support ventilation 1. However, the most recent and highest quality study, the BTS/ICS guideline, prioritizes informed adjustment of ventilator settings and patient-centered interventions to manage asynchronous breathing in BiPAP patients 1.
From the Research
Management of Asynchronous Breathing for BiPAP
Asynchronous breathing in patients on BiPAP (Bilevel Positive Airway Pressure) can be challenging to manage. The key to effective management lies in understanding the principles of BiPAP and its various modes.
- Understanding BiPAP: BiPAP is a type of non-invasive mechanical ventilation that delivers two different levels of air pressure, one for inhalation and a lower one for exhalation 2. This allows patients to breathe more easily and can help improve gas exchange.
- Modes of BiPAP: There are different modes of BiPAP, including spontaneous, timed, and spontaneous/timed modes. The choice of mode depends on the patient's condition and needs 3.
- Asynchronous Breathing: Asynchronous breathing occurs when the patient's breathing pattern does not match the ventilator's cycle. This can lead to increased work of breathing and discomfort for the patient 4.
- Management Strategies: To manage asynchronous breathing, healthcare providers can adjust the BiPAP settings, such as the inspiratory and expiratory pressures, and the respiratory rate. They can also try different modes of BiPAP, such as airway pressure release ventilation (APRV) or biphasic positive airway pressure (BIPAP) 5, 3.
- Patient-Ventilator Interaction: Patient-ventilator interaction is crucial in managing asynchronous breathing. The ventilator should be adjusted to match the patient's breathing pattern, and the patient should be encouraged to breathe in synchrony with the ventilator 6.
- Clinical Examples: Clinical examples have shown that asynchronous breathing can be managed effectively with BiPAP, but it requires careful adjustment of the ventilator settings and close monitoring of the patient's condition 5.
By understanding the principles of BiPAP and its various modes, and by using management strategies such as adjusting ventilator settings and promoting patient-ventilator interaction, healthcare providers can effectively manage asynchronous breathing in patients on BiPAP.