Management

1. Select type and delivery mode of ventilatory support.

2. Connect patient as per device instructions.

3. Use an appropriate sized mask that is comfortable and leak-free.

4. A delivered pressure of 10-15cmH2O is a usual starting point which can be adjusted according to patient response (respiratory rate, degree of fatigue, comfort, blood gases...).

5. Expiratory pressure support levels are usually within the 5-12cmH2O range.

6. Patients in respiratory distress may have initial difficulty in coping with these devices. Constant attention and encouragement help to accustom the patient to the device and/or mask while different levels of support, I:E ratios etc. are being tested to find the optimal setting. Cautious administration of low dose subcutaneous opiate injections (e.g. diamorphine 2.5mg) may help to calm the patient without depressing respiratory drive. The tight-fitting mask may be found increasingly claustrophobic after a few days' use. This should be pre-empted if possible by allowing the patient regular breaks. Pressure areas such as the bridge of the nose should be protected.

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