CPAP for EMS Shore EMS Conference 2010

1. We Can All Breathe a Little Easier with CPAP Brian D. King, AS, NREMT-P Christopher A. Johnson, BS, NREMT-P

6. What is CPAP? Continuous Positive Airway Pressure

7. 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

8. What are we using CPAP for? The treatment of respiratory distress secondary to Congestive Heart Failure (CHF) Other Respiratory Conditions: Pneumonia Asthma COPD

9. 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

10. 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

12. 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 noctournaldyspnea for 3 days Tonight started to “choke on phlegm” and developed trouble breathing

13. 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 CPAP?

14. 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

15. Anatomy & Physiology Review

17. Respiratory Cycle Two Phases Inspiration Expiraton

18. 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)

19. 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)

26. Four Chambers of the Heart Left Atrium Right Atrium Receives blood from veins; pumps to right ventricle. Receives blood from lungs; pumps to left ventricle. Right Ventricle Left Ventricle Pumps blood through the aorta to the body. Pumps blood to the lungs.

27. ASSESSMENT & PHYSICAL EXAM

28. INITIAL IMPRESSION Cyanosis Labored respirations Audible sounds Tripod position Frothy sputum Accessory muscle use O2 tubing

29. The ABC’S

30. VITALS SIGNS Interpreting Vital Signs Respirations SpO2 Pulse Blood Pressure Skin Physical Exam Lung Sounds

31. Respirations Adequate Respirations 12-20 Tidal Volume 500ml at rest Tachypnea Hypoxia Fever Pain Bradypnea Respiratory failure Impending respiratory arrest

32. Pulse OX >92% <75-80% accuracy greatly diminishes

33. Pulse Normal 60-100 Slow < 60 Rapid > 100 Irregular Regularly, Irregular Atrial Fibrillation

34. Blood Pressure Systolic 100-140 mmHg Diastolic 60-90 mmHg High vs. Low

35. Skin Color Normal Pale Others Temperature Hot Warm Cool Cold Condition Dry Moist Wet Edema

37. PITTING EDEMA

38. Lung Sounds Normal Rales / Crackels Rhonchi Wheezing Diminished

39. History

40. Clinical History Dyspnea at rest Dyspnea upon exertion Orthopnea Paroxysmal Nocturnal Dyspnea Cough Edema Chest Pain Abdominal Distention Diaphoresis Anxiety Smothering sensation

41. Past Medical History CHF Atrial Fibrillation Loss of atrial kick. MI Diabeties Renal Failure Dialysis Alcohol use Hypertension High Cholesterol

42. Medications Diruetics Lasix Bumex ACE Inhibitors Captopril Enalapril Lisinopril Cardiac Glycosides Digoxin Beta Blockers The “olol” drugs Beware of masked tachycardia

43. Heart Failure The inability of the heart to maintain an output adequate to sustain the metabolic demands of the body

44. Pulmonary Edema & Acute Pulmonary EDEMA An abnormal accumulation of fluid in the lungs

45. Conditions that mimic CHF

46. COPD Triad of distinct diseases that often coexist: Chronic Bronchitis Emphysema Asthma

47. Chronic Bronchitis Inflamatory changes and excessive mucous production in the bronchial tree Commonly caused by prolonged exposure to irritants

48. The “BLUE BLOATER”

49. 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

50. The “PINK PUFFER”

51. 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

52. Asthma

53. Pneumonia Infection in the lung, specifically the alveoli

54. CPAP

55. What EXACTLY IS CPAP?

56. Where does CPAP FALL

57. 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.

59. 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

61. 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

62. 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

63. 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

64. BUT WHAT HAPPENES TO THE FLUID?

65. The fluid is not being removed from the body by CPAP CPAP does not fix the entire problem

66. Things we may see Gastric distention Corneal drying Hypotension Pneumothorax Anxiety

67. CPAP ConTraindications Unconscious Inability to protect airway Respiratory Arrest Need for BVM or Intubation Vomiting Facial trauma Increased ICP (>20mmHg) – Unknown for us

68. Not a candidate for CPAP

71. 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.

72. 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. CPAP?

73. 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

74. CPAP DEVICES

76. Downs generator

77. Downs generator Requires a high pressure oxygen source Requires a complete CPAP system Closed system Easily adjustable PEEP

78. Boussignac

79. 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

81. CPAP Os

82. 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

83. CareVENT

84. 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

85. QUESTIONS? Contact us: Brian: Brian11884@aol.com Chris: EMTCJ64@aol.com