CPAP

1
Introduction of CPAP in EMS By Anthony Gorman
EMT-P, CIC AHA TCF
2
CPAP In Pre hospital EMSObjectives

• APE Pathophysiology review
• New Equipment review
• APE protocol 506 review
• Medication review

3
Introduction

• CPAP originated in Neonatal medicine. It was used
  on premature infants who lacked lung surfactant
  to keep the alveoli beds patent.

4
Background Data Controlled Studies

• Some EMS systems have already been using CPAP
  successfully for up to 10 years
• Cincinnati EMS studies showed
• Out of Hospital CPAP duration averaged 15.5
  minutes
• Mean length of stay 3.5 days for patients that
  did not require ETI and 11 days stay with ETI
• Galveston EMS studies showed
• ICU admission went from 100 to 48
• Average hospital stay decreased from 14.8 to 8
  days

5
Pulmonary Edema

• Swelling and/or fluid accumulation in the lungs
  resulting in impaired gas exchange.
• The respiratory system consists of millions of
  alveoli. The net function of the alveoli is to
  permit for the free exchange of oxygen and carbon
  dioxide.
• Increased pressure in the pulmonary blood vessels
  forces fluid into the alveoli, filling them and
  preventing the absorption of oxygen, this is
  known as pulmonary edema.

6
Common Causes

• Heart Failure (pump failure) our most common
  cause with high morbidity/mortality
• Infections (pneumonia)
• toxin exposure (IVDA)
• Medications
• Drowning, or near drowning
• High Altitude (HAPE)

7
Signs and Symptoms (Acute)

• Extreme shortness of breath or difficulty
  breathing
• A feeling of suffocating or drowning
• Wheezing or gasping for breath
• Anxiety and restlessness
• A cough that produces frothy sputum that may be
  tinged with blood
• Excessive sweating (diaphoresis)
• Pale skin
• Chest pain

8
Signs and Symptoms(progressive)

• Difficulty breathing when you're lying flat as
  opposed to sitting up (Orthopnea)
• Awakening at night with a breathless feeling
  (Nocturnal Dyspnea)
• Having more shortness of breath than normal when
  you're physically active (Dyspnea on exertion)
• Significant weight gain when pulmonary edema
  develops as a result of congestive heart failure,
  a condition in which the heart cannot meet the
  bodys needs.
• Pitting Edema and Jugular Vein Distention

9
Cardiogenic Causes

• Heart failure (Starlings Law cardiac
  contractility)
• Tachy/brady dysrythmias
• Myocardial Infarction
• Hypertensive crisis (Hydrostatic Oncotic
  pressure)
• Excess body fluids (ESRD - retention)
• Pericardial tamponade (increased effort)

10
Non-cardiogenic causes

• Inhalation of toxic gases
• Multiple blood transfusions
• Severe infection
• High energy trauma resulting in Pulmonary
  Contusion
• Multitrauma
• Neurogenic, i.e. cerebrovascular accident (CVA)
• Aspiration, i.e. gastric fluid or drowning
• Medications
• Upper airway obstruction
• High Altitude Sickness

11
Mechanisms

• Cardiac pulmonary edema, a.k.a. congestive heart
  failure (CHF), occurs when the left ventricle is
  not able to pump out enough of the blood it
  receives from the lungs. This causes pressure
  increases inside the left atrium and then in the
  pulmonary veins and capillaries, causing fluid to
  be pushed through the capillary walls.

12
Normal vs. CHF X-ray
13
Hypertension inducedHypertrophic Cardiomyopothy
14
Fluid Shifts

• This is a shift in the normal hydrostatic
  pressures within the capillary system. There are
  two components to pressure
• Force and Area.
• The more force, the larger the pressure the more
  area, the smaller the pressure.
• The net increase in local pressure results in a
  movement of fluid from the vascular
  (intravascular space) system into the aveoli.

15
CPAP Mechanisms

• Increases pressure within airways.
• Airways at risk for collapse from excess
• fluid are stented open.
• O2CO2 exchange is maintained
• Increased respiratory effort is minimized

16
CPAP vs.. Intubation

• CPAP
• Non-invasive
• Easily discontinued
• Easily adjusted
• Does not require sedation
• Comfortable

• Intubation
• Invasive
• Usually dont extubate Patients in field
• Potential for infection
• Requires highly trained personnel
• Can require sedation
• Traumatic

17
Pre-hospital Indications

• Congestive Heart Failure
• Pulmonary Edema associated with volume overload (
  renal insufficiency, iatrogenic volume overload,
  liver disease , etc)
• Near Drowning

18
WREMAC Protocol

• Be at least 14 years of age
• CARDIAC (General) Acute Pulmonary Edema /
  Congestive Heart Failure (SBP gt 100 mmHg)
• ?? STANDING ORDERS
• 1. NITROGLYCERIN 0.4 mg SL or spray (a) May be
  repeated every 5 minutes if SBP
• remains above 100 mmHg.
• 2. FUROSEMIDE 40 - 80 mg IVP.
• 3. Administer CONTINUOUS POSITIVE AIRWAY PRESSURE
  (CPAP) if available.
• 4. Obtain 12 LEAD EKG if possible.

19
discontinue if

• An immediate need for advanced airway control
  arises.
• The patient becomes hemodynamically unstable
• (BP lt 100 mm Hg systolic)
• The patient cannot tolerate the mask due to pain
  or discomfort.

20
Absolute Contraindications

• Respiratory Arrest
• Agonal Respirations
• Unconscious
• Shock associated with cardiac insufficiency
• Pneumothorax
• Facial Anomalies e.g. burns, fractures, etc.
• Facial trauma

21
Relative Contraindications

• ? L.O.C.
• COPD
• Asthma
• Claustrophobia
• Patient Intolerance to equipment (e.g. mask)

22
Hazards

• Gastric Distention (if pressures reach 15cm H2O
  pressure, it forces air past the epiglottis into
  the stomach, however at 25 lpm on your regulator
  there will be only 10cm H20 displaced)
• gt 20-30 cmH20 Can cause a detrimental decrease in
  venous return or LV preload, and cause profound
  hypotension
• High alveolar pressures can cause an over
  distention of alveoli resulting in
  atelectisis/pneumothorax
• Corneal Drying due to poor mask seal

23
CPAP Equipment
The Boussignac CPAP System unique features Low
O2 consumption rate -It uses only 15-25L/min.
for CPAP of 5-10 cmH2O. Only CPAP system that
does not need a flow generator. - Boussignac CPAP
only needs O2 source flowmeter -
No capital equipment to buy and repair
- Completely disposable, single use system
-Eliminates waiting at the hospital to
retrieve equipment Only completely open CPAP
system - Eliminates re-breathing Reduces risk
of barotrauma - Accommodates patients high
inspiratory peak demand - Permits use of
suction catheter without removing mask or loss
of CPAP - Allows use with a nebulizer
24
Equipment Continued...

• Easy to use
• - Boussignac CPAP set up in lt2 minutes,
  therefore ideal for all ER and EMS settings
• - Titrate CPAP simply by adjusting flow meter
• - No valves to change
• - Minimal training time
• Lightweight portable
• - Complete Boussignac System weighs only 6.8oz.
• - Fits easily into any airway bag or pocket (6
  x 5 x 4)

25
Equipment Continued...

• The Boussignac CPAP System works on the same
  principle as a turbine engine.
• The molecules of oxygen (or air) accelerate at
  the speed of sound as they pass through 4 micro
  channels. They strike a deflector that sends them
  into a central mixing zone.
• The collision of the molecules generates
  turbulence that transforms the speed (flow) into
  pressure, thus creating a virtual valve.

26
CPAP Application Procedure

• Apply supplemental oxygen therapy while
  assembling CPAP system components
• Prior to initiation of the CPAP mask, the patient
  must be informed of the purpose of the mask and
  explain what to expect from CPAP therapy.
• Constantly reassure the patient of the benefits
  of CPAP therapy for it may be uncomfortable and
  frightening.
• Maintain a semi to high fowlers head position

27
How it works
28
Operating Instructions

• Attach the Oxygen tubing tubing to both the
  oxygen supply and CPAP circuit to the appropriate
  size CPAP mask mask. There are no moving parts.
• Place on the face and gently adjust the straps to
  assure a good seal
• Adjust the oxygen flow rate from
• 15 lpm 5 cm H20
• 20 lpm 7.5 cm H20
• 25 lpm 10 cm H20

29
Boussignac CPAP SystemManufacturer's Slides

• Select the appropriate size face mask for your
  patient
• - Child Mask (Size 3)
• - Small Adult Mask (Size 4)
• - Medium Adult Mask (Size 5)
• - Large Adult Mask (Size 6)

30
Boussignac CPAP System

• Set Oxygen flow to deliver CPAP in cmH2O of water
  pressure
• - 15 liters 5cmH2O
• - 20 liters 7.5 cmH2O
• - 25 liters 10 cmH2O

31
Boussignac CPAP System

• Connect funnel end of Green Oxygen Tubing to an
  O2 source capable of delivering flow up to 25
  liters/min.
• This provides the full range of CPAP needed for
  clinical use (5-10cmH2O).
• Typically a D size cylinder in the field.

32
Boussignac CPAP System

• Insert white end of the Boussignac CPAP into the
  face mask.

33
Boussignac CPAP System

• If required, insert a pressure manometer between
  the Boussignac CPAP and the face mask.

34
Boussignac CPAP System

• Explain to the patient how the Boussignac CPAP
  will help their breathing.
• Gently hold the mask to the patients face
  insuring a good face/mask seal.
• Turn the flow control device to the desired
  liters/min, generally 15 l/min, to begin the
  CPAP.
• Gradually adjust the flow to achieve the desired
  level of CPAP.

35
Boussignac CPAP System

• Secure the Boussignac CPAP System to the patient
  with the head strap.
• Check around the mask for any leaks.
• Adjust the mask and/or head strap accordingly.

36
Boussignac CPAP System

• If the patient requires suctioning of the oral
  cavity, insert French size suction catheter
  through the open end of the Boussignac CPAP
  System.
• CPAP pressure will not be affected.

37
Boussignac CPAP System

• CO2 can be monitored with either a nasal cannula
  or an in-line CO2 adapter.

38
Boussignac CPAP System

• When transporting the patient in the ambulance,
  connect the Green Oxygen delivery tube to the
  wall Oxygen in the vehicle.

39
Boussignac CPAP System Nebulizer

• Fill the nebulizer with the prescribed
  medication.
• Currently there is no REMAC provision for CPAP
  nebulizer use

40
Boussignac CPAP System Nebulizer

• Insert the 22 mm male end of the nebulizer into
  the face mask.
• Insert the 22 male end (white) of Boussignac CPAP
  into the nebulizer.

41
Alveoli Pressure
? ? ? ? ?
42
Continued Reassessment During Operation

• Monitor to assure the there are no leaks with any
  of the connections
• Monitor the patients Vital Signs, Spo2, (and
  exhaled Co2 if available)
• Monitor and adjust for excessive mask seal leaks
• Monitor the units airway pressure gauge
  (Disposable Manometer)
• Monitor the supplemental oxygen tank pressure
  reserve
• Monitor patient for signs of improvement, mask
  tolerance, and/or further decompensation with a
  possible need for discontinuing therapy and
  initiate ETI

43
Protocol 506ACUTE PULMONARY EDEMA

• Begin BLS Respiratory Distress procedures.
• Begin Cardiac Monitoring, record and evaluate EKG
  rhythm.
• Begin an IV infusion of Normal Saline (0.9 NS)
  to keep vein open, or a Saline Lock.
• Monitor vital signs q 2-3 minutes.
• Administer NTG Tablet 1/150 gr or Spray 0.4 mg,
  sublingually, every 5 minutes, for a total of 3
• doses. Before each administration, check the
  patient's pulse and blood pressure to ensure the
  patient is hemodynamically stable.

44
Protocol 506ACUTE PULMONARY EDEMA

• NOTE UNLESS OTHERWISE DIRECTED BY ON-LINE
  MEDICAL CONTROL, PATIENTS WHO HAVE USED ERECTILE
  DYSFUNCTION MEDICATIONS IN THE PREVIOUS 72 HOURS
  SHALL NOT BE GIVEN NITROGLYCERIN AND/OR
  NITROPASTE.
• Administer Nitropaste 1½ inches (if available).
• NOTE UNLESS OTHERWISE DIRECTED BY ON-LINE
  MEDICAL CONTROL, NITROGLYCERIN AND/OR NITROPASTE
  MAY NOT BE ADMINISTERED TO PATIENTS WITH A
  SYSTOLIC BLOOD PRESSURE OF LESS THAN 100 mm Hg

45
Protocol 506ACUTE PULMONARY EDEMA continued

• Administer Furosemide 20 80 mg, IV/Saline Lock
  bolus. (Maximum combined total dosage is 80 mg.)
  Subject to change
• Initiate CPAP Therapy, if available, (see
  Appendix P)
• Contact Medical Control for implementation of one
  or more of the following MEDICAL CONTROL OPTIONS
• MEDICAL CONTROL OPTIONS
• OPTION A Administer Morphine Sulfate 0.1mg/kg
  (not to exceed 5mg), IV/Saline Lock bolus. Repeat
  doses of Morphine Sulfate 0.1mg/kg (not to exceed
  5mg) IV/Saline Lock bolus, may be given as
  necessary. (Maximum total dosage is 15 mg.)
• NOTE IF HYPOVENTILATION DEVELOPS, ADMINISTER
  NALOXONE UP TO 2 MG, IV/SALINE LOCK BOLUS
• OPTION B Administer Lorazepam 1 2 mg, IV/IN
  Saline Lock bolus.
• OR
• Administer Midazolam 1 2 mg, IV/IN Saline
  Lock bolus.
• OPTION C Repeat Nitroglycerin Tablet 1/150 gr.
  or Spray 0.4 mg, sublingually.
• OPTION D Transportation Decision.

46
Medications

• Nitro (Spray or Tab) Nitrate Arterial Venous
  Vasodilator, reduces cardiac preload
• Contraindications Hypotension, Severe Anemia,
  Trauma Intracranial bleeding, RVI, Severe Brady
  or Tachycardia, Viagra or other Erectile
  dysfunction drugs.
• Side Effects Headache, Dizziness, Syncope,
  Hypotension, Tachycardia, Facial flushing,

47
Medications Continued

• Furosemide Loop Diuretic, Antihypertensive
• Contraindications Dehydration, Oliguria, Fluid
  or Electrolyte depleted states. Pregnancy
  (Category C drug). Caution in Elderly.
• Side Effects Excessive Diuresis causing
  Dehydration, Electrolyte Imbalances, Hypotension,
  Abdominal cramping, Ototoxicity causing Tinnitus,
  Use with Caution in patients taking Digoxin
  (Digitalis toxicity).

48
Medications Continued

• Morphine Sulfate (OLMCC Required) Narcotic
  Analgesic further reduces Cardiac preload thus
  reducing pulmonary venous congestion, reduces
  pain and anxiety.
• Contraindications Head injury, Exacerbation
  COPD, ? respiratory drive, hypotension or volume
  depleted, Acute Abdomen, ? LOC
• Side Effects respiratory depression, ? in BP
  HR, ? LOC, Nausea Vomiting, miosis,
  diaphoresis, cool clammy skin.
• Keep Naloxone (Narcan) ready ?

49
Any Questions?