Bi-Level 

Purpose: 

To establish a guideline for the indications and application of Bi-Level Non Invasive Ventilation (NIV). 

Noninvasive ventilation (NIV): Refers to the administration of ventilatory support without using an invasive artificial airway (endotracheal tube or tracheostomy tube). In prehospital care, this can be provided by either: 

1. Continuous positive airway pressure (CPAP) 

2. Bi-level positive airway pressure (Bi-Level) Indications: 

Adult and Pediatric patients, > 12 years of age, in moderate to severe respiratory distress. Asthma, Bronchospasm, Croup, or Stridor: Shortness of Breath and who are: 

• Spontaneously breathing 

• Conscious 

• Able to maintain their own airway

Indications:  

• Severe Asthma  

• Chronic Obstructive Pulmonary Disease (COPD)  

• Near Drowning 

• respiratory distress that is not alleviated with simple breathing treatments

Contraindications: 

• • Agonal respirations or apneic patients

• Patient needs to be able to clear secretions and have no nausea or vomiting

• Suspected pneumothorax or chest trauma

  • Pediatric patients < 12 years of age 

  • Systolic Blood Pressure (SBP) < 80 mmHg in pediatric 

Assemble equipment 

1. Explain procedure to patient

2. Assist patient to use and tolerate the mask and circuit 

3. Use straps to maintain CPAP or BiPAP seal if needed 

4. Transport patient in a position that facilitates continuous visual monitoring and minimizes aspiration risk 

5. Document lung sounds before and after application of CPAP or BiPAP frequently or if clinical change. 

6. Starting CPAP pressure shall be 5 cm H2O. If using BiPAP set IPAP to 9 cm H2O and EPAP to 5 cm H2O. 

7. NIV support pressures may be increased for clinical effect 2.5-5 cm every 5 minutes. Use the lowest NIV pressures which result in clinical improvement to maintain O2 saturation > 90% and improve patient work of breathing. 

8. If a patient becomes unresponsive or has agonal respirations, remove CPAP or BiPAP and assist ventilations with BVM and airway adjuncts. 

9. Monitor patient and response to NIV. 

10. Notify the hospital that a NIV is in use so that equipment can be made available upon arrival at the hospital to continue. 

Medication Administration: 

A. FiO2 shall be titrated to the least amount needed to maintain SAO2 ≥ 94%. 

B. If indicated for wheezing, Albuterol 5 mg will be administered via in line nebulizer utilizing at least 8 liters per minute.

C. One time dose of Atrovent 0.5mg with Albuterol 5mg (duo-neb) is appropriate.