“Patient on BiPAP, very anxious,” our dispatch information reads.
BiPAP, short for bilevel positive airway pressure, is a form of respiratory therapy. In response to respiratory failure, patients wear a nasal cannula or a full face mask to receive pressurized air, opening up collapsed alveoli significant in the exchange of oxygen and carbon dioxide in the lungs.1
Our job is to transfer our patient from an ICU to a specialty hospital where they can receive long-term care. Before heading to the ICU, I inspect the levels on our oxygen tanks. This is a necessary precaution. According to our notes, the patient will require 50 to 65% FiO2. FiO2, or fraction of inspired oxygen, is the amount of oxygen in inhaled air.2
A functional adult-sized bag valve mask is a necessary item. If our machine fails, we’ll need an alternative method of delivering effective oxygenated breaths. I also ensure we have unopened, sterile suctioning equipment.
We arrive at the ICU to a group of concerned staff members. We are told the patient, Dahlia, is experiencing debilitating anxiety. Admitting diagnosis: shortness of breath and acute respiratory failure.
The physical sensation of breathlessness transcends and influences the mind, generating fear. When communicating with someone who is deeply and justifiably afraid, the situation requires presence of an equal depth.
“This is Steve,” says the nurse.
“Hello, Dahlia,” I say.
Before words are formed, I can see the reaction. Underneath a high-flow nasal cannula, eyes wide with shades of fear and a perceived futility of vocalizing her concerns, Dahlia speaks.
“I just want you to know,” she says, “I’m not trying to cause problems. But this is all so new to me. Suddenly I need this machine to breathe. And I’m a germaphobe. When you move me, please be careful. I’m terrified of falling on the ground….”
Dahlia continues to express her thoughts and emotions, and I listen intently. When she looks at me for my response, this is what I say: “I want you to know that I don’t interpret your emotions as ‘neediness’ or ‘rudeness.’ There’s a valid reason for your fear. You can’t catch your breath. Though the amygdala plays an important role in processing fear, chemoreceptors in the respiratory center of the brain also influence the fear response.”3
I then explain how this relates to Dahlia, specifically.
“When you can’t catch your breath, you retain carbon dioxide. This isn’t you overreacting. You’re reacting appropriately to an inner disturbance. It is scary to not be able to breathe. If you’re uneasy with anything we do, please let me know. Signal me. I will listen. It’s our responsibility to make this situation as comfortable for you as we can.”
Dahlia’s demeanor changes. She begins to relax. The more I speak with her, the less she embodies her fear. I go on.
“Our machine is going to feel different. Though you’re on a BiPAP machine here at the hospital, our ventilator does not have a BiPAP setting.”
Dahlia stops me.
“You said ‘ventilator.’ What do you mean by that? It scares me to hear the word ‘ventilator.’”
Dahlia is afraid. She wants to be heard and to understand what is going to happen to her. So, I continue to explain.
“Though the machine we are using is a ventilator, there are multiple modes and settings we can use. I’m going to set the machine to an ‘SIMV’ mode, meaning you will receive preset synchronized breaths, but you will also be able to take spontaneous breaths. When the machine senses you are breathing, it will delay the preset breath. You’ll get the help you need without being overpowered. You’re in control.”4
As Dahlia nods in understanding, I respond to her other concerns.
“When we transfer you to our stretcher, we’ll have a team of people to provide assistance. When we move, we’ll keep the bed low, and we will not let it tip over. You’re in good hands.”
Dahlia smiles and says, “my confidence is growing by the minute.”
I go on.
“Now, before we transfer you to our bed, I want you to know how it feels to be on our machine. So, I’m going to step out for a moment and get everything ready. I want you to be comfortable with your breathing before we do anything else.”
She responds with a genuine “thank you,” and I step out of the room.
I’m assisted by my team with setting up the ventilator circuits and getting our oxygen connected. I have Dahlia’s nurse call respiratory therapy so I can go over the settings I’ll need to program our ventilator. There are values that must be interpreted appropriately for the desired result, comfortable breathing.
I review the BiPAP settings with respiratory therapy. Inspiratory/expiratory pressures are 24/16. Oxygen is set at 50% FiO2. These are high settings. I’ll have to be vigilant.
The ICU’s BiPAP values: Inspiratory / expiratory pressure: 24 cm H2O / 16cm H2O. FiO2: 50%. Set respiratory rate: 18 breaths/minute. I-time: 0.75 seconds. Trigger sensitivity: -3 cmH20/mbar.
Patients often express that our ventilator feels “stronger” than a BiPAP or CPAP machines. When interpreting the hospital’s values, I tend to go lower in pressure so that I don’t overwhelm the patient and cause further anxiety. Then, if the pressure is too weak, I can always adjust and go higher at the patient’s comfort level.
My interpreted values: Pressure support (>PEEP): 20 cm H2O. PEEP: 8 cm H2O. FiO2: 50%. Set respiratory rate: 18 breaths/minute. Pressure control: 20 cmH20/mbar. I-time: 0.75 seconds. P-trig: -3 cmH20/mbar.
I tell Dahlia that there is a chance our machine will feel “stronger” than BiPAP. We’ll also have to use a full face mask because our circuit does not connect to the ICU’s nasal cannula.
“If there is any issue. If you find the pressure is too weak or strong, let me know and I will adjust the settings,” I say.
“Thank you, I will,” Dahlia replies.
The cannula is taken off and the face mask is put on. Our machine is now providing Dahlia with breaths given the values I provided.
“More oxygen. I need more oxygen,” she says, pointing to her mask.
With respiratory therapy’s approval, I increase the FiO2 from 50% to 65%. Dahlia gives me a thumbs up.
“How is the pressure? Is it too weak or too strong?” I ask.
“It feels a little weak,” Dahlia replies.
I increase the pressure support (>PEEP) from 20 cm H2O to 24 cm H2O. Another thumbs up. Dahlia tells me that she feels comfortable.
Dahlia is carefully transferred to our stretcher. I can feel that her trust in me is growing. I keep a close eye on our portable oxygen tank. We’re now at a quarter, or 500 psi. When we first arrived, we had a full tank. If we’re going to delay transport any longer, we’ll need more oxygen. Dahlia is still connected to the hospital’s cardiac monitor, blood pressure cuff and pulse oximeter. We still need to get the hospital’s equipment off. We’ll also need to account for the time it takes us to walk to the ambulance.
“We’re running low on oxygen,” I tell a member of my team. “I need you to run down to the ambulance and get us a full tank.”
He nods and walks to the elevators. It will be about five minutes. We don’t want to risk the portable tank running out, so an ICU staff member retrieves a larger tank from the supply room for temporary use. It’s a team effort, but the obstacles in our way don’t feel as burdensome when we communicate effectively and work together.
“There’s going to be 5 to 10 seconds that you don’t feel the oxygen. But understand this is temporary. I’m transferring you to the new tank,” I tell Dahlia.
“Okay, thank you,” she replies. She is calmer now.
“I’m going to breathe with you,” I say. “I’ve been under stress lately as well.”
Dahlia smiles and says, “okay.”
The rest of the call runs smoothly. We safely get Dahlia to the ambulance. She holds my hand briefly on the way to the specialty hospital.
“I’m going to let go now.” she says. And I know what this means. The fear is no longer controlling her. It may still be there, but she is not embodied by fear in this moment.
Explaining what is happening to the patient and allowing them to play a role in their own healing is important. We all want to feel in control of our bodies, minds, thoughts and emotions. While ventilators and BiPAP machines are physical tools, empathy and effective communication are intuitive and emotional tools, all of which help sustain our lifeforce – the breath.
- Caroline, N. L., Pollak, A. N., Elling, B., Aehlert, B., Mejia, A., Bortle, C.D. Respiratory Emergencies. In Nancy Caroline’s Emergency Care in the Streets. Eighth edition. Burlington, MA: Jones & Bartlett Learning; 2018. 933-935p.
- Caroline, N. L., Pollak, A. N., Elling, B., Aehlert, B., Mejia, A. Anatomy and Physiology. In Nancy Caroline’s Emergency Care in the Streets. Eighth edition. Burlington, MA: Jones & Bartlett Learning; 2018. 367p.
- Nestor, James. Hold It. In Breath. London, England: Penguin Life; 2020. 166-169p.
- Owens, W. Synchronized Intermittent Mandatory Ventilation. In The Ventilator Book. 3rd edition. Columbia, SC. First Draught Press; 2021. 113p.
Great article Steve. Well written mate.