We Can All Breathe a Little Easier with CPAP

Brian D. King, AS, NREMT-P

Christopher A. Johnson, BS, NREMT-P

What is CPAP?

Continuous

Positive

Airway

Pressure

Why CPAP

• Better for the patient

• Reduction in morbidity and mortality

• Less invasive then intubation

• Less complications than intubation

• Reduction in pre-hospital intubation

• Reduction in length of stays and ICU admissions

• It’s cost effective

What are we using CPAP for?

• The treatment of respiratory distress secondary to Congestive Heart Failure (CHF)

• Other Respiratory Conditions: • Pneumonia • Asthma • COPD

Evidenced Based Medicine

• Berstein, A. et al New England Journal of Medicine; 1991, 325:1825-1830• 65% reduction in ED ETI

• Lin M, Yang TG, Chiang, et al Chest; 1995: 107:1379-86• 75% reduction in ICU ETI

• Hastings, D., et al Journal of Emergency Medical Services; 1998 23(9):58-65• 85% reduction in PEC ETI• 50% reduction in ICU LOS

• Sacchetti, AD Harris, RH Postgraduate Medicine 1998 Feb;103 (2): 145-7, 153-4, 160-2• 90% averted ETI in ED

MORE Studies

• Cincinnati EMS • Mean LOS of 3.5 days for non ETI • Mean LOS of 11 days for ETI

• Galveston EMS• ICU admission decreased 52%• Avg LOS decreased from 14.8 to 8 days

Case Study #1

• 23:00 hours on a cool October evening

• Difficulty breathing (6D1)

• BLS is 6 minutes & ALS is 11 minutes from the scene

• 84 YOF

• CC: “Shortness of Breath”

• Increasing noctournal dyspnea for 3 days

• Tonight started to “choke on phlegm” and developed trouble breathing

Case STUDY #1

• Hx:• CHF, HTN

• Meds:• Lasix, Lisinopril, Coreg, Propoxyphene

• “Found in chair with moderate difficulty breathing on nasal O2 at 5lpm.”

• Initial Vital Sings: • Pulse: 120• Resp: 36• BP: 158/P

• SpO2: 90%

• GCS: 15• Lung Sounds: Bilateral Rales

CASE STUDY #1

• BLS applies NRB @ 15 lpm

• Three minutes latter places patient on CPAP with 10 of PEEP

• ALS arrives on scene and continues CPAP

• Vital Signs 12 minutes post CPAP:• Pulse: 104• Resp: 32• BP: 148/72

• SpO2: 97%

• GCS: 15

• Dx: • Pulmonary Edema due to heart failure

Anatomy & Physiology Review

Respiratory Cycle

• Two Phases • Inspiration • Expiraton

Inspiration

• Active process requiring muscles to have energy and function

• Diaphragm and intercostal muscles contract

• Diaphragm moves downward

• Ribs move upward and outward

• Increased chest size allows air to flow into the lungs (less pressure inside)

Exhalation

• Passive process allowing muscles to relax

• Diaphragm rises

• Ribs moves downward and inward decreasing chest cavity size

• Smaller chest size allows air to flow out of the lungs (less pressure outside)

Right Atrium

Right Ventricle

Left Atrium

Left Ventricle

Receives blood from veins; pumps to right ventricle.

Receives blood from lungs; pumps to left ventricle.

Pumps blood to the lungs.

Pumps blood through the aorta to the body.

Four Chambers of the Heart

ASSESSMENT & PHYSICAL EXAM

INITIAL IMPRESSION

• Cyanosis

• Labored respirations

• Audible sounds

• Tripod position

• Frothy sputum

• Accessory muscle use

• O2 tubing

The ABC’S

VITALS SIGNS

• Interpreting Vital Signs • Respirations

• SpO2

• Pulse• Blood Pressure • Skin

• Physical Exam • Lung Sounds

Respirations

• Adequate Respirations• 12-20• Tidal Volume

• 500ml at rest

• Tachypnea• Hypoxia • Fever• Pain

• Bradypnea • Respiratory failure • Impending respiratory arrest

Pulse OX

• >92%

• <75-80% accuracy greatly diminishes

Pulse

• Normal • 60-100

• Slow• < 60

• Rapid• > 100

• Irregular

• Regularly, Irregular• Atrial Fibrillation

Blood Pressure

• Systolic• 100-140 mmHg

• Diastolic• 60-90 mmHg

• High vs. Low

Skin

• Color• Normal

• Pale

• Others

• Temperature• Hot

• Warm

• Cool

• Cold

• Condition • Dry

• Moist

• Wet

• Edema

PITTING EDEMA

Lung Sounds

• Normal

• Rales / Crackels

• Rhonchi

• Wheezing

• Diminished

History

Clinical History

• Dyspnea at rest

• Dyspnea upon exertion

• Orthopnea

• Paroxysmal Nocturnal Dyspnea

• Cough

• Edema

• Chest Pain

• Abdominal Distention

• Diaphoresis

• Anxiety

• Smothering sensation

Past Medical History

• CHF

• Atrial Fibrillation• Loss of atrial kick.

• MI

• Diabeties

• Renal Failure

• Dialysis

• Alcohol use

• Hypertension

• High Cholesterol

Medications

• Diruetics• Lasix • Bumex

• ACE Inhibitors• Captopril • Enalapril • Lisinopril

• Cardiac Glycosides• Digoxin

• Beta Blockers • The “olol” drugs • Beware of masked tachycardia

Heart Failure

• The inability of the heart to maintain an output adequate to sustain the metabolic demands of the body

Pulmonary Edema & Acute Pulmonary EDEMA• An abnormal accumulation of fluid in the

lungs

Conditions that mimic CHF

COPD

• Triad of distinct diseases that often coexist: • Chronic Bronchitis • Emphysema• Asthma

Chronic Bronchitis

• Inflamatory changes and excessive mucous production in the bronchial tree

• Commonly caused by prolonged exposure to irritants

The “BLUE BLOATER”

Emphysema

• Characterized by: • Permanent abnormal

enlargement of the air spaces beyond the terminal bronchioles

• Destruction of the alveoli • Failure of the supporting

structures to maintain alveolar integrity

• Results in:• Reduced surface area • Reduced elasticity, leading to air

trapping • Residual volume increases while

vital capacity remains normal

The “PINK PUFFER”

Asthma

• Common chronic disorder of the airways that is complex and characterized by variable and recurring symptoms

• Asthma Triad: • Increased mucous production• Increased bronchial edema• Bronchospasm

Asthma

Pneumonia

• Infection in the lung, specifically the alveoli

CPAP

What EXACTLY IS CPAP?

Where does CPAP FALL

PEEP

• Positive End Expiratory Pressure• the amount of pressure above atmospheric pressure

present in the airway at the end of the respiratory cycle

• Goal of PEEP: • Improve oxygenation

• Amount of PEEP: • 5-10 cm H2O

• Too much PEEP:• >15 cm H2O may force air past the epiglottis

• >20-30 cm H2O can cause a decrease in venous return or LV preload causing hypotnesion.

What we are doing

• In pulmonary edema, fluid accumulates in the alveoli impairing gas exchange.

• CPAP increases the size of the airway and allows gas exchange to occur due to the increased surface area.

• CPAP changes the partial pressure of O2 in the blood

• Deoxygenated blood has a lower partial pressure of O2 in comparison to the air within the alveoli

• Oxygen diffuses from the alveolar air into the blood

What we want to do!

• Put more oxygen into the blood • Improving gas exchange

• Maintain a positive pressure in the lungs• Move some of the fluid out of the lung• Stops fluid from moving into the lungs

• Open the alveoli to preventing collapse

• Increasing the surface area in the alveoli will improve the gas exchange

• Increases intrathoracic pressure• Improves cardiac output to a degree• Too Much PEEP decreases cardiac output

What will we see?

• In a perfect world: • Improved gas exchange• Decreased anxiety • Improved vital signs

• Decreased blood pressure • Decreased pulse rate

• Increased SpO2

• Improved respiratory effort • Decreased respiratory rate

• Decreased need for intubation

• But we don’t live in a perfect world • Some patient’s will be too far gone and CPAP

will not turn the patient around • Some patient’s wont tolerate CPAP• Some patient’s will require intubation

BUT WHAT HAPPENES TO THE FLUID?

• The fluid is not being removed from the body by CPAP

• CPAP does not fix the entire problem

Things we may see

• Gastric distention

• Corneal drying

• Hypotension

• Pneumothorax

• Anxiety

CPAP ConTraindications

• Unconscious

• Inability to protect airway

• Respiratory Arrest

• Need for BVM or Intubation

• Vomiting

• Facial trauma

• Increased ICP (>20mmHg) – Unknown for us

Not a candidate for CPAP

Case Study #2

• 0028 hours

• “Interfacillity-Difficulty Breathing” 33C2

• BLS is 4 minutes & ALS is 10 minutes from the scene

• 90 YOF

• CC: “shortness of breath” per the staff

• Per staff “sudden onset of shortness of breath

• Staff relates that the patient began to “choke” on something.

Case Study #2

• Hx:• CHF, HTN, CVA, Atrial Fibrillation

• Meds:

• Furosemide, Norvasc, Nitro, Coumadin, Digoxin

• “Found laying in bed with a simple mask and gurgling respirations”

• Initial Vital Signs:• Pulse: 130• Resp: 40 and shallow• BP: 200/100• GCS: 9• Lung Sounds: Rale bilaterally

• BLS suctions the patient’s airway

• When sitting the patient up, patient has snoring respirations.

Case Study #2

• REMEMBER: Patient’s must have a self-maintained airway for CPAP applications.

• Airway management• Nasal • Oral • Positioning• Intubation

• Manual positive pressure ventilations may be preferred with a BVM

CPAP DEVICES

Downs generator

Downs generator

• Requires a high pressure oxygen source

• Requires a complete CPAP system

• Closed system

• Easily adjustable PEEP

Boussignac

Boussignac

• Currently used for the NCC BLS Pilot Study.• Low investment • No additional equipment• Completely Disposable • As simple as applying a non-rebreather• Small Size

• Open system • Eliminates rebreathing • Able to suction using a French catheter without

losing pressure• Allows use of a nebulizer

CPAP Os

CPAP OS

• High Cost for the system

• Requires a high pressure oxygen source

• Requires a complete CPAP system

• Closed system

• Easily adjustable PEEP with large guage

CareVENT

Carevent

• High cost

• Offers the best of both worlds • Transport ventilator for intubated patients• CPAP

• Requires a high pressure oxygen source though consumes less oxygen in comparison to other models

• Requires a complete CPAP system

• Closed system

QUESTIONS? Contact us:

Brian: Brian11884@aol.comChris: EMTCJ64@aol.com