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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 noctournaldyspnea 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 CPAP?
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
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)
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.
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
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
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. CPAP?
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
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
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