Table 4.

Use of noninvasive ventilation and extubation culture quotes

Themes	Quote
Use of noninvasive ventilation	All of a sudden, a patient’s not breathing well. We come at them with this mask that’s blowing like a ShopVac. In fact, it’s in your face. It scares people. And you put it on; even though it’s helping them, they have the perception that it’s making things worse. So we have to really educate the patient. And then while they’re on it, we need to continue to make sure that they’re tolerating it well. Be aware of skin breakdown. Change masks periodically, and make sure that we’re getting therapeutic… 02_RT You can’t understand [patients on NIV]. They want to talk to you and they get frustrated because we can’t hear them because they’re muffled. And then they get anxious. And then they get more short of breath, and their sats drop even lower. Their mouth is super dry because of the air flow. They’re constantly asking for water and the majority of families don’t understand that you can’t take the mask off every five minutes to swab their mouth. They’re hungry. They want to eat. They don’t understand why they can’t. Communication’s the biggest thing though… 01_RN
	Well if you don’t have to intubate the patient, then you don’t have to get into difficulties with sedation, hypotension related to sedation. You know, [NIV] decreases the length of stay in the intensive care unit, decreases morbidity, mortality… 02_MD
Extubation culture	So my usual practice is that if somebody has a borderline spontaneous breathing trial, I might wait another day to try to reassess the risk to see if they can optimize the medical therapy and try to being a little more grounded into the establishment of the patient before extubation. 03_MD I just feel that if you go to that, you’re going to use that, like I said before, I feel like they’re not ready to be extubated if you’re going to use the BIPAP. That’s my perspective on that. I’m not the doctor. I just feel like they’re not ready to be extubated so why extubate them and throw them on that BIPAP… 02_RT
	Mostly BiPAP, especially if they’re COPD or something at baseline. Not for airway disease at baseline. Most of the time that would be the plan. We extubate them to BiPAP for a while trying to kind of non-invasively ventilate them for a while and transition to just oxygen. 01_MD COPD patients. Stuff like that, sometimes we would … or if … it’s kind of borderline iffy. “Should we pull the tube? Should we not pull the tube?” sometimes they would pull it and perform BiPAP, too. Q: How often is that? A: I feel not that often. Most of the time, we’re pretty sure [on extubating]. 04_RT So let’s just extubate to bipap, not as often here, because they are not real pro-BiPAP… 04_RT
	The BiPAP, while it does a great job giving oxygen and talking away the work of breathing, easing the work of breathing, it dries out secretions and it pushing secretions deeper. Patients can’t cough. I think it causes more trouble than it’s worth. Patients with bad chronic lung disease, COPD, pulmonary fibrosis, BiPAP’s great. We use it a lot, very successfully, but I’ve used a lot of Optiflow. It’s heated. It’s humidified. People feel much more comfortable with it on. 04_MD and usually I will try Airvo before I try bipap. But I would like to try the Airvo first since we’re not putting the mask back on somebody and make them more uncomfortable than they really need to be. 04_RT

Definition of abbreviations: BiPAP = bilevel positive airway pressure; COPD = chronic obstructive pulmonary disease; MD = physician; NIV = noninvasive ventilation; RN = nurse; RT = respiratory therapist.