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CPAP for EMS
Shore EMS Conference 2010

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  • 1. We Can All Breathe a Little Easier with CPAP
    Brian D. King, AS, NREMT-P
    Christopher A. Johnson, BS, NREMT-P
  • 2.
  • 3.
  • 4.
  • 5.
  • 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
  • 11.
  • 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
  • 16.
  • 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)
  • 20.
  • 21.
  • 22.
  • 23.
  • 24.
  • 25.
  • 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
  • 36.
  • 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.
  • 58.
  • 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
  • 60.
  • 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
  • 69.
  • 70.
  • 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
  • 75.
  • 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
  • 80.
  • 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