A patient w/ an anoxic brain injury was put on CPAP 10 and cool aerosol @.28FiO2 by fact tent; the patient was mouth breathing due to severe sinusitis(worsened by ETT in recent days), so large air leak existed. Her tongue had minimal tone, but CPAP was effective at keeping airway patency and SpO2 100%. This therapy was questioned(specifically the face tent aerosol) as not keeping with the "standard of care". I am interested in feedback. AACR guidelines do not address, as far as I can determine. Although perhaps unconventional, the patient's secretons remained hydrated, she was hemodynamically stable, oxygenated and her airway open. Any thoughts or suggestion?

You didn't mention what kind of interface the CPAP was being used with. Is it safe to assume that you were using a nasal mask? Also, it appears that you were transferring the pt. back and forth between CPAP and face tent? What was the purpose of the CPAP in the first place - was it to splint the airway? Was it used only during "sleep?" Could the pt. cough and/or follow commands? I think you may have been challenged in your use of the CPAP due to the fact that with any most types of brain injury, the patient's ability to maintain spontaneous respirations is questionable at best. You just never know when they will go apneic, or, in this case, aspirate and then have the pressure from the CPAP drive the aspirant right into the lungs. We probably would have monitored for secretion clearance and done periodic oximeter spot checks until discharge. Nasal trumpets are helpful in minimizing trauma during NTS. If there is no hope for rehab., pts. like this should be evaluated for tracheostomy.