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Shore EMS Conference 2010

Published in: Health & Medicine


  1. 1. We Can All Breathe a Little Easier with CPAP<br />Brian D. King, AS, NREMT-P<br />Christopher A. Johnson, BS, NREMT-P<br />
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  6. 6. What is CPAP?<br />Continuous <br />Positive <br />Airway <br />Pressure<br />
  7. 7. Why CPAP<br />Better for the patient <br />Reduction in morbidity and mortality<br />Less invasive then intubation<br />Less complications than intubation<br />Reduction in pre-hospital intubation<br />Reduction in length of stays and ICU admissions <br />It’s cost effective <br />
  8. 8. What are we using CPAP for?<br />The treatment of respiratory distress secondary to Congestive Heart Failure (CHF) <br />Other Respiratory Conditions: <br />Pneumonia <br />Asthma <br />COPD <br />
  9. 9. Evidenced Based Medicine<br />Berstein, A. et al New England Journal of Medicine; 1991, 325:1825-1830<br />65% reduction in ED ETI<br />Lin M, Yang TG, Chiang, et al Chest; 1995: 107:1379-86<br />75% reduction in ICU ETI<br />Hastings, D., et al Journal of Emergency Medical Services; 1998 23(9):58-65<br />85% reduction in PEC ETI<br />50% reduction in ICU LOS <br />Sacchetti, AD Harris, RH Postgraduate Medicine 1998 Feb;103 (2): 145-7, 153-4, 160-2<br />90% averted ETI in ED<br />
  10. 10. MORE Studies <br />Cincinnati EMS <br />Mean LOS of 3.5 days for non ETI <br />Mean LOS of 11 days for ETI<br />Galveston EMS<br />ICU admission decreased 52%<br />Avg LOS decreased from 14.8 to 8 days<br />
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  12. 12. Case Study #1<br />23:00 hours on a cool October evening<br />Difficulty breathing (6D1) <br />BLS is 6 minutes & ALS is 11 minutes from the scene<br />84 YOF<br />CC: “Shortness of Breath”<br />Increasing noctournaldyspnea for 3 days <br />Tonight started to “choke on phlegm” and developed trouble breathing<br />
  13. 13. Case STUDY #1<br />Hx:<br />CHF, HTN<br />Meds:<br />Lasix, Lisinopril, Coreg, Propoxyphene<br />“Found in chair with moderate difficulty breathing on nasal O2 at 5lpm.”<br />Initial Vital Sings: <br />Pulse: 120<br />Resp: 36<br />BP: 158/P<br />SpO2: 90%<br />GCS: 15<br />Lung Sounds: Bilateral Rales<br />CPAP?<br />
  14. 14. CASE STUDY #1<br />BLS applies NRB @ 15 lpm<br />Three minutes latter places patient on CPAP with 10 of PEEP<br />ALS arrives on scene and continues CPAP<br />Vital Signs 12 minutes post CPAP:<br />Pulse: 104<br />Resp: 32<br />BP: 148/72<br />SpO2: 97%<br />GCS: 15<br />Dx: <br />Pulmonary Edema due to heart failure<br />
  15. 15. Anatomy & Physiology Review <br />
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  17. 17. Respiratory Cycle <br />Two Phases <br />Inspiration <br />Expiraton<br />
  18. 18. Inspiration<br />Active process requiring muscles to have energy and function <br />Diaphragm and intercostal muscles contract<br />Diaphragm moves downward<br />Ribs move upward and outward<br />Increased chest size allows air to flow into the lungs (less pressure inside) <br />
  19. 19. Exhalation<br />Passive process allowing muscles to relax<br />Diaphragm rises <br />Ribs moves downward and inward decreasing chest cavity size<br />Smaller chest size allows air to flow out of the lungs (less pressure outside) <br />
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  26. 26. Four Chambers of the Heart<br />Left Atrium<br />Right Atrium<br />Receives blood from veins; pumps to right ventricle.<br />Receives blood from lungs; pumps to left ventricle.<br />Right Ventricle<br />Left Ventricle<br />Pumps blood through the aorta to the body.<br />Pumps blood to the lungs.<br />
  28. 28. INITIAL IMPRESSION<br />Cyanosis <br />Labored respirations <br />Audible sounds <br />Tripod position <br />Frothy sputum <br />Accessory muscle use <br />O2 tubing <br />
  29. 29. The ABC’S<br />
  30. 30. VITALS SIGNS<br />Interpreting Vital Signs <br />Respirations <br />SpO2<br />Pulse<br />Blood Pressure <br />Skin<br />Physical Exam <br />Lung Sounds <br />
  31. 31. Respirations<br />Adequate Respirations<br />12-20<br />Tidal Volume<br />500ml at rest <br />Tachypnea<br />Hypoxia <br />Fever<br />Pain<br />Bradypnea<br />Respiratory failure <br />Impending respiratory arrest<br />
  32. 32. Pulse OX<br />>92%<br /><75-80% accuracy greatly diminishes <br />
  33. 33. Pulse <br />Normal <br />60-100<br />Slow<br />< 60 <br />Rapid<br />> 100<br />Irregular <br />Regularly, Irregular<br />Atrial Fibrillation <br />
  34. 34. Blood Pressure<br />Systolic<br />100-140 mmHg<br />Diastolic<br />60-90 mmHg<br />High vs. Low<br />
  35. 35. Skin<br />Color<br />Normal <br />Pale <br />Others <br />Temperature<br />Hot<br />Warm <br />Cool<br />Cold <br />Condition <br />Dry<br />Moist <br />Wet<br />Edema<br />
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  37. 37. PITTING EDEMA<br />
  38. 38. Lung Sounds<br />Normal<br />Rales / Crackels<br />Rhonchi<br />Wheezing <br />Diminished<br />
  39. 39. History<br />
  40. 40. Clinical History <br />Dyspnea at rest<br />Dyspnea upon exertion<br />Orthopnea<br />Paroxysmal Nocturnal Dyspnea<br />Cough <br />Edema<br />Chest Pain<br />Abdominal Distention<br />Diaphoresis <br />Anxiety <br />Smothering sensation <br />
  41. 41. Past Medical History <br />CHF <br />Atrial Fibrillation<br />Loss of atrial kick.<br />MI <br />Diabeties<br />Renal Failure <br />Dialysis <br />Alcohol use <br />Hypertension<br />High Cholesterol <br />
  42. 42. Medications <br />Diruetics<br />Lasix<br />Bumex<br />ACE Inhibitors<br />Captopril<br />Enalapril<br />Lisinopril<br />Cardiac Glycosides<br />Digoxin<br />Beta Blockers <br />The “olol” drugs <br />Beware of masked tachycardia <br />
  43. 43. Heart Failure<br />The inability of the heart to maintain an output adequate to sustain the metabolic demands of the body<br />
  44. 44. Pulmonary Edema & Acute Pulmonary EDEMA<br />An abnormal accumulation of fluid in the lungs<br />
  45. 45. Conditions that mimic CHF<br />
  46. 46. COPD<br />Triad of distinct diseases that often coexist: <br />Chronic Bronchitis <br />Emphysema<br />Asthma <br />
  47. 47. Chronic Bronchitis<br />Inflamatory changes and excessive mucous production in the bronchial tree<br />Commonly caused by prolonged exposure to irritants<br />
  48. 48. The “BLUE BLOATER”<br />
  49. 49. Emphysema<br />Characterized by: <br />Permanent abnormal enlargement of the air spaces beyond the terminal bronchioles<br />Destruction of the alveoli <br />Failure of the supporting structures to maintain alveolar integrity<br />Results in:<br />Reduced surface area <br />Reduced elasticity, leading to air trapping <br />Residual volume increases while vital capacity remains normal <br />
  50. 50. The “PINK PUFFER”<br />
  51. 51. Asthma<br />Common chronic disorder of the airways that is complex and characterized by variable and recurring symptoms<br />Asthma Triad: <br />Increased mucous production<br />Increased bronchial edema<br />Bronchospasm<br />
  52. 52. Asthma<br />
  53. 53. Pneumonia<br />Infection in the lung, specifically the alveoli<br />
  54. 54. CPAP<br />
  55. 55. What EXACTLY IS CPAP?<br />
  56. 56. Where does CPAP FALL<br />
  57. 57. PEEP<br />Positive End Expiratory Pressure<br />the amount of pressure above atmospheric pressure present in the airway at the end of the respiratory cycle<br />Goal of PEEP: <br />Improve oxygenation <br />Amount of PEEP: <br />5-10 cm H2O<br />Too much PEEP:<br />>15 cm H2O may force air past the epiglottis <br />>20-30 cm H2O can cause a decrease in venous return or LV preload causing hypotnesion.<br />
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  59. 59. What we are doing<br />In pulmonary edema, fluid accumulates in the alveoli impairing gas exchange. <br />CPAP increases the size of the airway and allows gas exchange to occur due to the increased surface area. <br />CPAP changes the partial pressure of O2 in the blood <br />Deoxygenated blood has a lower partial pressure of O2 in comparison to the air within the alveoli <br />Oxygen diffuses from the alveolar air into the blood <br />
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  61. 61. What we want to do!<br />Put more oxygen into the blood <br />Improving gas exchange<br />Maintain a positive pressure in the lungs<br />Move some of the fluid out of the lung<br />Stops fluid from moving into the lungs<br />Open the alveoli to preventing collapse<br />Increasing the surface area in the alveoli will improve the gas exchange <br />Increases intrathoracic pressure<br />Improves cardiac output to a degree<br />Too Much PEEP decreases cardiac output<br />
  62. 62. What will we see?<br />In a perfect world: <br />Improved gas exchange<br />Decreased anxiety <br />Improved vital signs<br />Decreased blood pressure <br />Decreased pulse rate<br />Increased SpO2<br />Improved respiratory effort <br />Decreased respiratory rate<br />Decreased need for intubation <br />
  63. 63. But we don’t live in a perfect world <br />Some patient’s will be too far gone and CPAP will not turn the patient around <br />Some patient’s wont tolerate CPAP<br />Some patient’s will require intubation<br />
  65. 65. The fluid is not being removed from the body by CPAP<br />CPAP does not fix the entire problem<br />
  66. 66. Things we may see<br />Gastric distention <br />Corneal drying <br />Hypotension <br />Pneumothorax<br />Anxiety<br />
  67. 67. CPAP ConTraindications<br />Unconscious<br /> Inability to protect airway<br />Respiratory Arrest <br />Need for BVM or Intubation<br />Vomiting <br />Facial trauma<br />Increased ICP (>20mmHg) – Unknown for us<br />
  68. 68. Not a candidate for CPAP<br />
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  71. 71. Case Study #2<br />0028 hours <br />“Interfacillity-Difficulty Breathing” 33C2<br />BLS is 4 minutes & ALS is 10 minutes from the scene<br />90 YOF <br />CC: “shortness of breath” per the staff<br />Per staff “sudden onset of shortness of breath <br />Staff relates that the patient began to “choke” on something. <br />
  72. 72. Case Study #2<br />Hx:<br />CHF, HTN, CVA, Atrial Fibrillation<br />Meds: <br />Furosemide, Norvasc, Nitro, Coumadin, Digoxin<br />“Found laying in bed with a simple mask and gurgling respirations”<br />Initial Vital Signs:<br />Pulse: 130<br />Resp: 40 and shallow<br />BP: 200/100<br />GCS: 9<br />Lung Sounds: Rale bilaterally <br />BLS suctions the patient’s airway<br />When sitting the patient up, patient has snoring respirations. <br />CPAP?<br />
  73. 73. Case Study #2<br />REMEMBER: Patient’s must have a self-maintained airway for CPAP applications. <br />Airway management<br />Nasal <br />Oral <br />Positioning<br />Intubation<br />Manual positive pressure ventilations may be preferred with a BVM <br />
  74. 74. CPAP DEVICES<br />
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  76. 76. Downs generator<br />
  77. 77. Downs generator<br />Requires a high pressure oxygen source <br />Requires a complete CPAP system<br />Closed system<br />Easily adjustable PEEP <br />
  78. 78. Boussignac<br />
  79. 79. Boussignac<br />Currently used for the NCC BLS Pilot Study.<br />Low investment <br />No additional equipment<br />Completely Disposable <br />As simple as applying a non-rebreather<br />Small Size <br />Open system <br />Eliminates rebreathing<br />Able to suction using a French catheter without losing pressure<br />Allows use of a nebulizer<br />
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  81. 81. CPAP Os<br />
  82. 82. CPAP OS<br />High Cost for the system <br />Requires a high pressure oxygen source <br />Requires a complete CPAP system<br />Closed system<br />Easily adjustable PEEP with large guage<br />
  83. 83. CareVENT<br />
  84. 84. Carevent<br />High cost<br />Offers the best of both worlds <br />Transport ventilator for intubated patients<br />CPAP<br />Requires a high pressure oxygen source though consumes less oxygen in comparison to other models<br />Requires a complete CPAP system<br />Closed system<br />
  85. 85. QUESTIONS? <br />Contact us: <br />Brian:<br />Chris:<br />