Prehospital CPAP

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Prehospital CPAP Provider Training
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Acknowledgements

• Dave Pavlakovich, RRT,
• University of Texas Medical Branch, Galveston, TX
• Dave Henning, NREMT-P, CCP
• Gold Cross Ambulance Service, Manasha, WI

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Topics For Today

• -Overview of Respiratory Mechanics
• -Most Common Respiratory Dysfunctions
• -What is CPAP?
• -How Can We Use CPAP?
• -Exclusions
• -Protocols
• -Assessment
• -Data Collection
• -Practical

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Respiratory Mechanics

• Components of the Airway

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Respiratory Mechanics

• Oxygenation and Ventilation

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Respiratory Mechanics

• Functional Residual Capacity

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Respiratory Mechanics

• Peak Inspiratory Flow

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Common Dysfunctions
Obstructive vs. Restrictive Disorders
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Common Dysfunctions
COPD
Obstructive Issues Gas Exchange Issues Muscle
Tiring
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Common Dysfunctions
Acute Pulmonary Edema
Pressure Changes and fluid shift VQ
Mismatch Distress and sympathetic discharge
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Diagnosis of APE

• Symptoms
• Acute onset shortness of breath
• Physical exam findings
• Rales, legs
• Pedal edema
• JVD
• Chest XRay findings for CHF
• Echocardiograms Low ejection fraction/poor
  contractility (hypocontractility)

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How do you know an EMS patient has Heart Failure?

• Ask 3 Questions
• 1. History of Congestive Heart Failure?
• 2. RALES on Lung Examination?
• 3. EDEMA to Legs?

Burton , J. CHF in EMS 2005
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What Is CPAP
Continuous Positive Airway Pressure

• Breathing Against A Threshold of Resistance
• Pneumatic Splinting of Airways
• Oxygen Therapy In Its Most Efficient Form

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What Is CPAP

• In Our Program.
• -Mask
• -Tubing
• -Gas Source
• -PEEP Regulation
• -Generator

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What Is CPAP

• In Our Program.
• -Air is mixed with oxygen via a venturi system or
  with a Downs Flow Generator

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What Is CPAP

• -Resistance is regulated with a positive end
  expiratory pressure (PEEP) valve.

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What Is CPAP
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Effects of CPAP

• -Increased Functional Residual Capacity
• -Reduced Work Of Breathing
• -Increased Oxygen Diffusion Across Alveolar
  Membrane
• -Increased Alveolar Surface Area

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Effects of CPAP

• Acute Pulmonary Edema
• Changes Pressure Gradients
• Reduces Work of Breathing Sympathetic Discharge
• Can Decrease Preload

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CPAP therapy can improve A.P.E. patients in 90
seconds.
CPAP was associated a decrease in need for
intubation (-26) and a trend to a decrease in
hospital mortality (-6) compared with standard
therapy alone. (Pang, D. et al. 1998. Data
review 1983-1997. Chest 1998 114(4)1185-1192)
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How We Can Use CPAP

• Acute Pulmonary Edema
• CPAP is to APE like D50 is to insulin shock
• Russell K. Miller Jr, MD, FACEP

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But Maine has many inexperienced providers
What about misdiagnosis?
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2003 Helsinki EMS Looked at patients in Acute
Severe Pulmonary Edema (ASPE) 121 patients
included Used low concentration FiO2, IV Nitrates
and No lasix 4 patients intubated in field
Mean O2 Saturation From 77-90 Hospital
mortality 17.8 (non CPAP)-8 (CPAP) Only 83
patients were confirmed to have chf (Kallio, T.
et al. Prehospital Emergency Care. 2003. 7(2) )
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Keep in mind Helsinki -34 (non chf) of 121 still
got better There is sparse research anecdotal
evidence for use in other etiologies
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Limitations of CPAP

• CPAP IS NOT MECHANICAL VENTILATION!

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Limitations of CPAP

• Other Limitations
• -Increased Intrathoracic Pressure Can Produce
  Hypotension
• -Psychological Effects
• -Pneumothorax
• -Corneal Drying

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Limitations of CPAP

• Oxygen Demand
• Time (f X PSI) / LPM

Tanks at 1000 PSI D (f 0.16) 1-2
Minutes E (f 0.28) 2-4 Minutes M (f
1.59) 10-20 Minutes H (f 3.18) 19-38
Minutes
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CPAP Indication

• -APE
• -Acute respiratory insufficiency

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CPAP Indication
Acute respiratory insufficiency will be defined
as moderate/severe respiratory distress of 5 word
or less dyspnea concurrent with signs and
symptoms of hypoxia (cyanosis, pulse oximetry
readings of less than 90, etc.), and/or
accessory muscle use.
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CPAP Exclusions

• -Patient lt 18
• -Unstable Airway
• -Traumatic Etiology of Respiratory. Distress
• -Severe Altered Mental Status
• -Facial Trauma or Impossible Face Seal

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CPAP Protocol

• Intermediate and Above-Standing Order

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CPAP Protocol

• APE
• MEMS Protocols Plus
• -Medical Control
• -CPAP Option
• Reassess, Reassess, Reassess!

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CPAP Protocol

• Psychological Therapy
• Address the emotional component
• Dont give up too early but know when to say
  when.

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Reassess, Reassess, Reassess!
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MEMS Approved CPAP Systems

• Whisper Flow, Oxypeep,

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MEMS Approved CPAP Systems

• Port-O-Vent, Boussignac

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CPAP SYSTEMS

• Oxypeep

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CPAP SYSTEMS

• Boussignac

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CPAP SYSTEMS

• Boussignac

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CPAP Documentation
Necessary Elements  Initial Assessment System
Utilized Medical Control Requests 5 Minute
Assessment Arrival Condition
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Documentation
Modified Borg Scale  0-No breathlessness at
all 1-Very slight 2-Slight breathlessness
3-Moderate 4-Somewhat severe 5-Severe
7-Very severe 9-Very, very severe (Almost
maximum) 10-Maximum
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Practical Session
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QUESTIONS?