Paramedic Rounds Pre-Hospital Continuous Positive Airway Pressure (CPAP) · PDF fileParamedic...

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Paramedic Rounds

Pre-Hospital Continuous Positive

Airway Pressure (CPAP)

Morgan Hillier MD Class of 2011Dr. Mike Peddle Assistant Medical Director

SWORBHP

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Objectives• Outline evidence for pre-hospital CPAP• Describe normal pulmonary anatomy and physiology

• Describe abnormal pulmonary A&P leading to acute respiratory emergencies

• Describe the mechanism of action of CPAP• Describe the indications, conditions and contraindications for pre-hospital CPAP

• Describe approach to monitoring a patient receiving CPAP and possible complications

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Why CPAP in EMS?

• Hubble MW et all (2006)• Compared to similar EMS systems• System with CPAP protocol showed

• Decreased intubation rate• Decreased mortality• Decreased hospital length of stay

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Why CPAP in EMS?

• Thompson J et al (2008)• Randomized controlled trial• Patients randomized to CPAP treatment group:

• Decreased intubations• Decreased mortality

• No studies have shown evidence of harm

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The Respiratory System

• Architecture of the lung

• similar to an inverted tree-like structure with progressively smaller airways

• Leads to terminal bronchi and • alveoli

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• Alveoli• The Functional units of respiration• Contain surfactant

• Liquid which decreases surface tension• Prevents alveoli from “sticking together”

• Alveolar collapse leads to decreased lung volume• Decreased blood oxygen (hypoxemia)• Increased blood CO2 (Hypercarbia)

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• Muscles of Respiration• Diaphragm exerts negative pressure on Lungs• Intercostal muscles cause chest excursion• Exhalation is a passive process (elastic recoil)

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• Respiratory Distress:• Accessory muscles such as sternocleidomastoids and scalenes increase chest excursion

• At rest, healthy person uses ~4% of oxygen to fuel respiratory muscles

• During acute respiratory emergency, may use up to 20% of oxygen to fuel respiratory effort

• Increased oxygen demand with work of breathing

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Pathophysiology

• Common conditions leading to resp distress:• Cardiogenic Pulmonary Edema• Chronic Obstructive Pulmonary Disease• Asthma• Pneumonia

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Cardiogenic Pulmonary Edema

• Secondary to congestive heart failure (CHF)• Left ventricular failure leads to backward pressure and vascular congestion in lungs

• Increased hydrostatic pressure causes leakage of fluid into alveoli

• Reduces gas exchange leading to hypoxia• “washes out” surfactant leading to alveolar collapse (atelectasis)

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Pulmonary Edema

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Decreased gas exchange due to fluid build up and alveolar collapse

Acute Pulmonary Edema

• Patient short of breath with increased work of breathing and diffuse inspiratory crackles in all lung fields

• Potentially decreased air entry at bases due to alveolar collapse (atelectasis)

• Patient often has history of coronary artery disease and or cardiac risk factors such as HTN, DM, Hyperlipidemia and family cardiac history

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Chronic Obstructive Pulmonary Disease• Pt has chronic airway disease elicited on history usually with a history of long-term cigarette exposure

• Bronchitis – chronic inflammation characterized by scarring of airways and increased mucous production

• Emphysema – characterized by loss of elasticity of lung parenchyma with destruction of alveoli

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COPD Exacerbation

• Usually precipitated by respiratory infection • Acute SOB• Increased work of breathing• Excess secretions (CLEAR productive cough) • Potentially leads to respiratory failure

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Asthma

• Bronchospasm secondary to irritant or allergic stimulus

• Patient presents with • Expiratory wheeze• May progress to insp/expiratory wheeze• Eventually silent chest with no appreciable ventilation to affected area of lungs

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Asthma

• Patient has history of asthma and often a recognized inciting event (“trigger”)

• Treated with bronchodilators and 100% oxygen via NRB mask

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Pneumonia

• Bacterial, viral or fungal infection of the lung• Generally a focal area of infection• Patient presents with

• Fever• productive cough• localized chest pain• focal inspiratory crackles

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Non-Invasive Positive Pressure Ventilation (NIPPV)• Continuous Positive Airway Pressure (CPAP)• Bi-level Positive Airway Pressure (BIPAP)

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How does CPAP work?

• Tight fitting mask controlled by a regulator with high-flow oxygen

• Flow restriction device on exhalation port exerts continuous positive pressure on airways

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Main Effects

• Splints airways open• Positive pressure decreases leakage of fluid into alveoli

• Positive pressure decreases work of breathing and oxygen requirements

• Improves cardiac function by decreasing preload and afterload on the heart

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Cardiogenic Pulmonary Edema

• CPAP:• Decreased leakage of fluid into lungs• Splints airways• Decreases work of breathing/O2 Requirments• Decreases atelectasis

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• CPAP:• Splints airways• Decreases atelectasis• Decreases work of breathing and oxygen requirements

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Asthma

• CPAP Contraindicated!

• Air-trapping/hyperinflation• Potential to do harm• Focus on bronchodilators and 100% oxygen

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Pneumonia

• CPAP Contraindicated!

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CPAP Indications

• Patient awake and able to follow commands• Meets at least two of the following:

• Resp rate 24 or greater• SpO2 less than 90%• Accessory muscle use

• AND with signs and symptoms consistent with • Exacerbation of chronic obstructive pulmonary disease OR

• Acute pulmonary edema

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CPAP Conditions

• Age 12 years or greaterOR• Weight 40Kg or greater

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CPAP Contraindications

• Resp distress due to other medical condition• Asthma• Pneumonia

• Condition that may be worsened by CPAP• Pneumothorax• Systolic BP <90• Major trauma or burns (face, neck, chest, abdo)

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CPAP Contraindications

• Other intervention required• Unable to cooperate, decreased mentation, inability to sit upright

• Unable to maintain airway, intubated patient, facial abnormality, tracheostomy

• Resp rate < 8• Cardiac arrest

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Patient Monitoring

• Assess for:• Decreased Respiratory Rate• Increased SpO2• Subjective improvement in dyspnea• Decreased anxiety

• Vitals q5min with particular attention to:• Blood pressure• Adequacy of ventilation

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Complications

• Hypotension• Conversion of pneumo to tension pneumo• Airway obstruction• Requires continuous oxygen supply• Relies on patients respiratory rate• Intolerance of mask • Vitals q5min and constant patient monitoring!

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Questions???

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Paramedic Rounds Pre-Hospital Continuous Positive Airway Pressure (CPAP) · PDF fileParamedic...

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