Presentation on theme: "PAP Positive airway pressure (PAP) adjuncts are used to mobilize secretions and treat atelectasis and include continuous positive airway pressure (CPAP)"— Presentation transcript:
1PAPPositive airway pressure (PAP) adjuncts are used to mobilize secretions and treat atelectasis and includecontinuous positive airway pressure (CPAP)positive expiratory pressure (PEP)expiratory positive airway pressure (EPAP).Cough or other airway clearance techniques are essential components of PAP therapy when the therapy is intended to mobilize secretions
2PAP: CPAPThe patient breathes from a pressurized circuit against a threshold resistor (water-column, weighted, or spring loaded) that maintains consistent preset airway pressures from 5 to 20 cm H2O during both inspiration and expiration(By strict definition, CPAP is any level of above-atmospheric pressure.)CPAP requires a gas flow to the airway during inspiration that is sufficient to maintain the desired positive airway pressure.
3PAP: CPAPTypes of threshold resistors: all of these valves operate on the principle that the level of PAP generated within the circuit depends on the amount of resistance that must be overcome to allow gas to exit the exhalation valve.They provide predictable, quantifiable, and constant force during expiration that is independent of the flow achieved by the patient during exhalation
4PAP: CPAP Underwater seal resistor: Weighted-ball resistor: expiratory port of the circuit is submerged under a column of water, the level of CPAP is determined by the height of the columnWeighted-ball resistor:consists of a steel ball placed over a calibrated orifice, which is attached directly above the expiratory port of the circuit
5PAP: CPAP Spring-loaded: Magnetic valve resistors rely on a spring to hold a disc or diaphragm down over the expiratory port of the circuit.Magnetic valve resistorscontain a bar magnet that attracts a ferromagnetic disc seated on the expiratory port of the circuit the amount of pressure required to separate the disc from the magnets is determined be the distance between them.
6PEP does not require a pressurized external gas source. PAP: PEPThe patient exhales against a fixed-orifice resistor, generating pressures during expiration that usually range from 10 to 20 cm H2OPEP does not require a pressurized external gas source.The amount of PEP varies with the size of the orifice and the level of expiratory flow produced by the patient. The smaller the orifice the greater the pressure.
7PAP: PEPThus the patient must be encourage to generated a flow high enough to maintain expiratory pressure at mm H2OIdeal I:E of 1:3 or 1:4The patient should perform breaths through the device and then perform 2-3 huff breath coughsThis should be repeated 5-10 times during a minute session
8PAP: EPAPThe patient exhales against a threshold resistor, generating preset pressures of 10 to 20 cm H2O (similar to CPAP expiration)EPAP does not require a pressurized external gas source.EPAP utilizing threshold resistors does not produce the same mechanical or physiologic effects that PEP does when a fixed orifice resistor is used.Further study is necessary to determine how these differences affect clinical outcome.
11IPPBIntermittent Positive Pressure Breathing (IPPB) is a short-term breathing treatment where increased breathing pressures are delivered via ventilator to help treat atelectasis, clear secretions or deliver aerosolized medicationsIPPB can include pressure- and time-limited, as well as pressure, time, and flow-cycled ventilation.IPPB may be delivered to artificial airways and non-intubated patients.
12IPPBINDICATIONS: The need to improve lung expansion The presence of clinically significant pulmonary atelectasis when other forms of therapy have been unsuccessful (incentive spirometry, chest physiotherapy, deep breathing exercises, positive airway pressure) or the patient cannot cooperate
13IPPBInability to clear secretions adequately because of pathology that severely limits the ability to ventilate or cough effectively and failure to respond to other modes of treatmentThe need for short-term ventilatory support for patients who are hypoventilating as an alternative to tracheal intubation and continuous mechanical ventilation
14IPPB The need to deliver aerosol medication. IPPB may be used to deliver aerosol medications to patients with fatigue as a result of ventilatory muscle weakness (eg, failure to wean from mechanical ventilation, neuromuscular disease, kyphoscoliosis, spinal injury) or chronic conditions in which intermittent ventilatory support is indicated (eg, ventilatory support for home care patients and the more recent use of nasal IPPV for respiratory insuff iciency)
15IPPB Assessment of need: Presence of significant atelectasis Reduced pulmonary function, reduced VC, VTNeuromuscular disordersPrevention of atelectasisAssessment of Outcome:Minimum VT of at least 1/3 of predicted ICIncrease in FEV1More effective cough, CXR improved, BS improved
16IPPBCONTRAINDICATIONS: There are several clinical situations in which IPPB should not be used. With the exception of untreated tension pneumothorax, most of these contraindications are relative:Increased ICP >15 mmHgHemodynamically unstableRecent Facial, oral or skull surgeryTracheoesphogeal fistula
17IPPB Recent Espohageal surgery Active hemoptysis Nausea Air swallowing Active TBBlebsSingulation (hiccups)
18IPPB Hazards/complications Increased RAW and WOB Barotrauma/pneumothoraxNosocomial infectionHypocarbiaHemoptysisHyperoxia when O2 used as gas sourceGastric distensionImpaction of secretions
19IPPB Impendance of venous return Air trapping Limitations of Device Effects are short lived, lasting an hourDelivery of medication is ineffective due to low delivering flow through nebulizerPatient dependentIPPB equipment is labor intensiveLimited portability
20IPPB IPPB is pneumatically powered Patient triggered and pressure cycledYou set: Pressure limit, flow, sensitivity
21IPPB Given through a mouth piece or mask Varying types, BIRD Mark series, PB
22IPPB Setup Flow rate adjustment. Sensitivity adjustment Pressure adjustmentAir mix, either 100% if pushed in or 80% pulled outPressure manometer. Negative should not be more than -2, if it is adjust your sensitivity
23IPPB How the machine works: In IPPB, we set a driving pressure [PIP] on the machine, and when the patient triggers the machine by decreasing the pressure in the line, gas starts to move down the tube into the mouth and airways.When the preset PIP is reached, the gas flow shuts down immediately. The inspiratory phase has cycled off.
24IPPB: PressurePressure set on the IPPB will determine the pressure limitPressure is directly related to volume, increasing the pressure limit will increase the volume in the lungMeasure VT withVenti-comp bag
25IPPB PressurePressure is typically started low, around cmH2O and increased to achieve desired VT. Remember, IPPB is hyperinflation therapy, the goal is to exceed normal tidal volume ranges.Once the machine is triggered on by the patient and pressure is reached (seen on manometer) the machine cycles offToo much pressure can cause barotrauma
26IPPB FlowThe flow setting on the IPPB dictates how fast the pressure limit is reachedHigh flow = low inspiratory timeLow flow = high inspiratory timeStart low around 5-10 L and increase depending on the desired inspiratory timeNormal times should be around seconds for inspiration
27IPPB FlowTo decrease the inspiratory time we need to increase the flow rateTo increase the inspiratory time, we need to decrease the flow rateIf we increase the PIP to increase the VT, sometimes the inspiratory time is too long and we have to increase the flow rate.Remember that really fast flow rates will only cause increased RAW, so keep the inspiratory time between seconds for adults.Remember that the air mix mode involves air entrainment so the flow rate will be changed by changing the Fi02
28IPPB SensitivityThe sensitivity on the IPPB machine is manipulated by the dial on the left hand side of the machine. Increasing the “Inspiratory Effort” dial will make the machine less sensitive to the patients inspiratory trigger. This increases the magnetic pull inside the sub atmospheric side of the ,IPPB bird machine making it more difficult for the patient to trigger the machine on, increasing WOB
29IPPB SensitivityDecreasing the “patient effort” dial will make the machine more sensitive to the patients inspiration.This may cause “auto-triggering” if it is set too low.Decreasing this dial creates less magnetic pull on the diaphragm in the middle of the machine
30IPPB FIO2If you do not wish to deliver high FIO2 to the patient during the IPPB procedure, attach the machine to a air outlet, otherwise the only two FIO2 available are 100% or 80% with air dilutionNOTE: on the IPPB machine there is a APNEA- expiratory time setting, do not turn this on unless you want a back up rate.
31Breathing while on IPPB Remember, this is not ventilation. IPPB is a sustained maximal inspiration just like IS, so we do not need to breathe much faster than 6-8 bpm. The patient may breathe faster, but he can do so off the IPPB. Rapid RR on the IPPB will increase chances of impeding venous return to the heart, reducing the amount of blood in the heart which would cause the patient to become tachycardiac in order the keep the same cardiac output.
32Breathing while on IPPB If the patient becomes light headed, dizzy or feels tingling in their fingers during the procedure- STOP and allow patient to rest, this is caused by the quick elimination of CO2Rapid RR will encourage air trapping, particularly in persons with increased RAW and wheezing—we need plenty of time to exhalation
33Breathing while on IPPB We need to allow for a 3-5 second inspiratory hold.Remember this is a SMI, that includes a slow deep breath and inspiratory hold to get the gas and the medications deep into the periphery of the lung. The patient can take his mouth off the IPPB mouthpiece to do this breath hold—unless we need to measure the VT.
34IPPB TroubleshootingIf you checked your PIP by watching the monometer while you occlude the patient connector, you will find most problems before attaching the machine to the patient. The pressure should go right to the PIP and stop immediately. The machine should not start just because you jiggle the tube.Is the machine set for appropriate Fi02?Is the sensitivity set for -2?Check the PIP by monometer—not just the number on the dialIs the circuit on nice and tight-do a tactile exam, not just looking at it.If the SVN is set separately, is it set correctly?
35IPPB Troubleshooting Breath will not come on 1. attach the high pressure line to the gas2. turn on the flow rate3. check the sensitivity; set the machine to trigger by itself [auto-cycling] then turn back a bit.4. does the patient have a tight seal? Mouth closed? Lips tight, nose closed or nose clips?
36IPPB Troubleshooting Breath starts too easily 1. sensitivity is set too low. Auto-cycling is when the machine triggers itself just by jiggling the tube. Breath will not end1. check the flow rate; too slow2. does the patient have a tight seal? Mouth closed? Lips tight, nose closed or nose clips? LEAKS3. check the mushroom valve, the nebulizer line, the nebulizer cup and the mainline for leaks.
37IPPB Troubleshooting Inhalation goes on past 1-1.5 seconds 1. flow rate is too slow for this patient2. check for small leaks that prevent the pressure from rising. Look at the pressure on the monometer, there should be a steady rise in pressure3. if the pressure is wavering just lower than the PIP, the patient is ‘leading the machine.’ Ask him to relax & let the machine do the work.He is inhaling too fast—also increase the flow rate per his comfort level4. if you moved from air mix to 100% Fi02, you lost the entrainment so the flow rate needs to be increased again
39IPVIntrapulmonary percussive ventilation (IPV) is a therapeutic modality designed to clear and maintain pulmonary airways. IPV is used to mobilize and clear retained secretions, assist in the resolution of atelectasis, and to deliver aerosolized medications. Oscillatory pulsations are delivery by the "Percussionator" which generates high frequency bursts of gas at rates of 100 to 300 cycles per minute (2 – 5 Hz). The mini bursts of air are delivered to the patient's airways at pressures of 10 – 20 cm H20, however this range may be adjusted to match the compliance and resistance of the lung and chest wall.
40IPVIPV was depicted as delivering “high flow mini-bursts of air along with bronchodilator to the lungs at a rate of 300–400 times per minute.”operates at 1.7 Hz to 5 Hz and generates esophageal pressure and airflow oscillationsTreatments last about 15–20 minThis device is designed to be used in conjunction with conventional mechanical ventilation, if desired, or as a stand-alone treatment device. It can be used with a mouthpiece or mask, and it can also deliver aerosolized medication.
41IPV http://www.youtube.com/watch?v=ARJLALFf2e0 Pneumatically powered Nebulizer cup, uses a phasitron to create oscillations, bacterial filter, circuit- colored coded- connect lines to deviceSet Drive pressure (based on patients compliance)Set percussion level
42PEEPPositive end-expiratory pressure (PEEP) is the pressure in the lungs (alveolar pressure) above atmospheric pressure that exists at the end of expiration. The two types of PEEP are extrinsic PEEP (PEEP applied by a ventilator) and intrinsic PEEP (PEEP caused by a non-complete exhalation).
43PEEP There are three purposes to using PEEP: 1) To prevent derecruitment, by returning the functional residual volume to the physiologic range. 2) To protect the lungs against injury during phasic opening an closing of atelectatic units.3) To assist cardiac performance, during heart failure, by increasing mean intrathoracic pressure.
44PEEPApplied (Extrinsic) PEEP — Applied PEEP can be given through invasive or non-invasive ventilation.Works by increasing alveolar pressure to increase FRC, Mean Airway pressure and ultimatley improve compliance and improve oxygenationPEEP is given in the range of about 3-5 and used to mitigate end-expiratory alveolar collapse. A higher level of applied PEEP (>5 cmH2O) is sometimes used to improve hypoxemia or reduce ventilator-associated lung injury in patients with acute lung injury, acute respiratory distress syndrome, or other types of hypoxemic respiratory failure
46A: Collapsed alveoli on exhalation without PEEP B: Inflated alveoli on exhalation with PEEPC: Inflated alveoli on inspiration with PEEP
47Auto-Peep (Intrinsic Peep) Auto-PEEP is gas trapped in alveoli at end expiration, due to inadequate time for expiration, bronchoconstriction or mucus plugging. It increases the work of breathing.Auto-PEEP is caused by gas trapped in alveoli at end expiration. This gas is not in equilibrium with the atmosphere and it exerts a positive pressure, increasing the work of breathing,
48Auto-Peep (Intrinsic Peep) The problem with gas trapping or “auto PEEP” is that gas trapped in the airways exerts a positive pressure, and normal gas transit cannot be reestablished until there is a pressure gradient from the mouth to the alveoli. Thus the patient must generate a much higher negative inspiratory pressure to open up dynamically compressed airways (to make the pressure within negative with respect to atmospheric pressure).If auto-PEEP occurs during mechanical ventilation, the amount of time given over to expiration needs to be lengthened: either by reducing the respiratory rate or the inspiratory time, or both.
54CPAPCPAP is the application of continuous positive airway pressure, patient is breathing spontaneously. Pressure is at one levelCPAP is a mode, and also a settingSynonymous with PEEP, and EPAPGiven for a variety reasons, including:Refractory hypoxemiaOSARDS…
55CPAPCPAP can be applied non-invasively, through a BiPAP machine, CPAP machine, or SiPAP machine or it can be given invasively through a continuous mechanical ventilatorCPAP is otherwise known as PEEP, can be given to all age groups
58NPPVApplication of positive pressure without airway intubation for the purpose of augmenting alveolar ventilationPatient’s using NPPV are typically awake/alert and breathing spontaneously
59Goals of NPPV Acute Care Avoid intubation Improve mortality Relieve symptomsEnhance gas exchangeImprove ventilator-patient synchronyMaximize patient comfortDecrease incidence of ventilator-acquired pneumonia (VAP)
60Goals of NPPV Chronic Care Relieve or improve symptoms Enhance quality of lifeAvoid hospitalizationIncrease survivalImprove mobility
61Indications for NPPV Disease states Asthma Used in treatment of acute attack to avoid intubation, HHN can be given inlineMany tend to be claustrophobic and don’t tolerate procedureAcute exacerbation of COPDStudies indicate that NPPV should be first-line intervention in treatmentOnly beneficial in acute exacerbation/HHN treatment can be given inlineAcute cardiogenic pulmonary edemaAdministered as first-line treatment, NO HHN treatment indicatedNot recommended for patients with myocardial infarction, arrhythmias, hemodynamic instability, or depressed mental status
62Indications for NPPV Other indications Neurologic/neuromuscular diseaseShould always be considered as a first-Line treatmentWorks well when applied to patients with progressively deteriorating diseaseWill use NPPV until the patient requires invasive PPVWeaning from ventilatory supportMay be indicated for patients who have failed at weaning attempts but for whom clinical signs indicate they should be weanedMay be used with patients failing extubation
63Indications for NPPV Other indications Immunosuppressed patients/patients awaiting lung transplantAvoidance of intubation – leads to nosocomial pneumoniaShould always be considered as a first-Line treatmentAcute lung injuryShould be applied with caution to ALI patientsIf no response within a few hours, patient should be intubatedDNR patients (controversial)Used to prolong life until family members arriveUsed to transport patient home to dieProvide comfort during last hours of life
64Indications for NPPV Chronic care settings Relief of nocturnal hypoventilation in COPD patientsNocturnal use for restrictive thoracic diseasesRest respiratory musclesLower PaCO2 to establish new baseline valueImprove lung compliance, lung volume, and reduce dead spaceTreat nocturnal hypoventilationObesity hypoventilationObstructive sleep apneaCentral sleep apnea
65NPPV for OSAPatients with OSA often use CPAP via face, nasal or nasal pillow masks. Often poorly tolerated.
66NPPV for OSAObstructive sleep apnea (OSA) is the most common type of sleep apnea and is caused by obstruction of the upper airway. It is characterized by repetitive pauses in breathing during sleep, despite the effort to breathe, and is usually associated with a reduction in blood oxygen saturation. These pauses in breathing, called apneas (literally, "without breath"), typically last 20 to 40 seconds.The individual with OSA is rarely aware of having difficulty breathing, even upon awakening. It is recognized as a problem by others witnessing the individual during episodes or is suspected because of its effects on the body (sequelae). OSA is commonly accompanied with snoring.Leads to cardiac problems, brain problems, HTN…
67Selection Criteria for NPPV in Acute Respiratory Failure Use of accessory musclesParadoxical breathingRespiratory rate > 25 breaths/minDyspnea (moderate to severe or increased over normal levels)PaCO2 > 45 mmHg with pH < 7.35PaO2/FIO2 ratio < 200
68BiPAP Two levels of non-invasive positive pressure. BiPAP is a trademarked name from RespironicsIPAP: Inspiratory positive airway pressure, a pressure limit, increases in IPAP = increases in VTEPAP: Expiratory positive airway pressure, PEEP, applied on expiration to increase FRCSet IPAP and EPAP at least 5 apart to create a pressure gradient, this difference is called pressure support
69Bipap The BiPAP machine has two basic modes: S/T (Spontaneous timed): You set a IPAP, EPAP, Rate, inspiratory time and FIO2. The rate only applies when the patient falls below the minimum back up rate, once he or she does the machine is termed time cycled. Otherwise all breaths are spontaneously triggered. Set alarmsCPAP: Set a PEEP/EPAP level, along with FIO2, no back up rate set. Watch for apnea, set apnea alarm
70Bipap Typical settings for Bipap: IPAP cmH2O (increase or decrease based on PaCO2)EPAP 5-10 cmH2O (increase/decrease based on PaO2)Rate 6-10 (rate set low, patient should be breathing spontaneously)FIO % (based on SpO2, PaO2…)I-time 1.0 second (usually a non issue since rate is low)Rise time 0.4 seconds (only applies to timed breath)Once BiPAP is applied, assess comfort, monitor Vte, RR, HR, SpO2, BP, cardiac rhythm, Ve…Get a ABG about 1-2 hours after initiationLeaks are the number one cause of alarm
71BiPAPBipap is typically setup quickly with the mask being the most cumbersome aspect of setupBiPAP should be used as a temporary means of augmenting/ assisting in a patients respiratory distress. Prolonged use typically suggests the patient may need intubationCommonly used in the ER for CHF/pulmonary edema, but also for a wide range of other reasons
72Bipap The most important factors in applying BiPAP are: Is the patient a proper candidate for BiPAP or do they need to be intubatedNote contraindications for deviceIs the mask appropriate for the patient (correct size and fit)Proper settings
73Exclusion Criteria for NPPV in Acute Respiratory Failure Apnea (NPPV/BIPAP only for spontaneously breathing pts)Hemodynamic instabilityUncooperative patient behavior (may need sedation)Facial burns or other traumaCopious secretions (Devices can dry secretions)High risk of aspirationAnatomic abnormalities that interfere with gas delivery
74Exclusion Criteria in the Chronic Care Setting Unsupportive familyLack of financial resourcesUncooperative patient behaviorCopious secretionsHigh risk of aspirationAnatomic abnormalities that interfere with gas deliveryVentilatory support required most waking hours
75Administration of NPPV – Patient Interfaces Nasal maskTriangular in shape; made to fit around the noseMost common interfaceFitting of mask dependent upon manufacturer’s specificationsLeakage through the mouth can be a significant problem, may need chin strap
76Administration of NPPV – Patient Interfaces Full face masksSurrounds nose and mouth, resting below lower lipSeal easier to maintain because both mouth and nose coveredAssociated with increased dead space, risk of aspiration, and claustrophobiaAsphyxiation can occur in Ventilator failure so alarms must be functional
77Administration of NPPV – Patient Interfaces Nasal pillowsConsists of two small cushions that fit under the noseHas limited pressure range of use – 3 to 20 cmH2OMore comfortable than facial masks, but gas leakage may be a problem. Gas leaks out of the mouth, may need chin strap
78Administration of NPPV – Patient Interfaces Total face maskSurrounds entire faceOne size available for quick application in emergenciesDoes have increased dead space, but decreases claustrophobic feeling because it does not obscure visionAlternate masks to reduce pressure sores on face
79Administration of NPPV – Humidification Heated humidification has been noted to decrease nasal resistance and congestionCold passover humidification does not significantly relieve nasal resistanceHeated humidification increases patient compliance with the procedure
80Administration of NPPV – Initiation Successful application requires that the patient be part of the process. They must understand what is to be done and be fully cooperative in the process.
81Administration of NPPV – Initiation Place patient at an angle ≥ 30⁰Determine correct size and type of patient interface (very important, if patient is uncomfortable they are non-compliant)Attach patient interface to circuitSelect initial settingsPEEP: 0 – 4 cmH2OVentilating pressure: < 5 cmH2O (typically 10-15)Expected VT: 200 – 500 mLOnce you input your settings and alarms connect to patient
82Administration of NPPV – Initiation Select initial settingsFIO2: maintain SpO2 > 90%Rate: determined by patient, again set low
83Administration of NPPV – Initiation Hold the mask on the patient’s face or have the patient hold the mask on the faceWhen patient is comfortable with mask, use straps to hold in placeDo not overly tighten or let too loose
84Administration of NPPV – Initiation Adjust FIO2 as necessary to maintain SpO2 > 90%Adjust mask as necessary to correct any air leaks, do not put tape on mask to prevent leaks. Ensure exhalation ports are open
85Administration of NPPV – Initiation As patient becomes comfortable, adjust inspiratory positive airway pressure (IPAP) until VT is between 4 and 6 mLs/kg or until signs of respiratory distress improve
86Administration of NPPV – Initiation Increase expiratory positive airway pressure (EPAP or PEEP) to reduce dyssynchrony from air trapping or to improve oxygenation
87Administration of NPPV – Assessment Assessment after initial two hours indicating successful administrationDecrease in PaCO2Increase in pHIncrease in PaO2Decreased WOB
88Administration of NPPV – Assessment Assessment after initial two hours indicating successful administrationDecrease in respiratory rateNormalization of heart rate and respiratory rateNormalization of ventilatory pattern
89Administration of NPPV – Assessment Failure to observe improvement requires reassessment to determine need for intubationIf patient shows some signs of improvement, continue to evaluate to determine success or failure of procedure and initiate appropriate actionNPPV should be used as a short term application, or used on a nightly or intermittent basis
90Administration of NPPV – Assessment Be cautious to avoid prolongation of the procedure; allowing patient to continue too long without significant improvement can create difficulties for intubation or stabilization later
91Side Effects Side Effect Possible Remedy Mask related Discomfort Facial skin erythemaClaustrophobiaNasal bridge ulcerationAcneiform rashCheck fit, adjust strap, change to new type ofmaskLoosen straps, apply artificial skinUse a smaller mask, change type of mask,give sedativeLoosen straps, apply artificial skin, changemask typeAdminister topical steroids or antibioticsAir pressure or flow relatedNasal congestionSinus or ear painNasal or oral drynessEye irritationGastric insufflationsAdminister nasal steroids, decongestant, orantihistaminesReduce pressure if pain is intolerableApply nasal saline solution, add humidifier,decrease leakCheck mask fit, readjust strapsReassure the patient, give simethicone,reduce pressure to relieve excessive pain
92Side Effects Side Effect Possible Remedy Air leaks Encourage mouth closure, try chin straps, tryoronasal mask if using nasal mask, reducepressure slightlyMajor complicationsAspiration pneumoniaHypotensionPneumothoraxSelect patients carefullyReduce IPAPStop ventilation if possible, reduce airwaypressure; insert chest tube if indicated
93Side EffectsSlow skin breakdown by applying Mepilex or DuoDerm tape to patient’s face, typically the bridge of the nose and forehead and sides of face
94Contraindications Absolute Untreated pneumothorax Patient without a paten airwayApneaInability to fit interface due to deformity
96HW assignment Michaines@hotmail.com Part 1. Assess the use and application of IPPB and IPV as a means for hyperinflation and bronchial hygiene therapy. Is there evidence supporting there effective use? (2 pages)Part 2. Explain why or why not the use of BiPAP in DNR patients is justified. I want your opinion on the ethical implications as well as the functionality of the Bipap as a ventilation assistant(2 pages)Use peer reviewed literature to write a minimum of two pages on each topic. You may me your articles or attach them with your paper. Use correct referencingDUE OCTOBER 8th