1. Continuous Positive
Airway Pressure
For EMT Providers
State Education & Training Committee
December 2012

2. Goal
 The student will be able
to correctly utilize
service specific CPAP
devices in a respiratory
compromised patient
 [img]http://hammondems.com/images/d_1976.jpg

3. Objectives
 At the completion of this training, the BLS
provider will:
 Describe respiratory anatomy and physiology
 Verbalize understanding of respiratory
disorders / illnesses
 Appreciate the benefits and limitations of
CPAP in alleviating patient symptoms
 List indication and contraindications for use.

4. Anatomy and Physiology
of Respiration

5. Respiratory Physiology
 Nose / Mouth
 Trachea
 Mainstem Bronchi
 Secondary Bronchi
 Tertiary Bronchi
 Bronchioles
 Terminal Bronchiole
 Alveoli
 Diaphragm
 http://www.uni.edu/schneidj/webquests/spring04/offtowar/respiratory.html

6. InhalationInhalation
 Active process
 Negative
pressure pulls air
into lungs
continued

7. Exhalation
 Passive process
 Muscles relax;
size of chest
decreases
 Positive pressure
created; air
pushed out
continued

8. Negative Pressure
 Respiration driven by process of negative
intrathoracic pressures
 Negative pressure
 Initiates inhalation and acquires O2
 Assists to increase intrathoracic blood flow
 Equalization of pressures
 initiates exhalation and elimination of CO2

9. Bronchi / Bronchioles
 Cartilage structures give
way to smooth muscle
 May divide up to 25
times before reaching
terminal bronchioles
http//medicalpicturesinfo.com/bronchial-tree/

10. Alveoli
 Expand and contract with breathing
 Contact with pulmonary capillary beds for gas
exchange
 Inside surface coated with surfactant
 Prevents aveoli from sticking together
 Keeps alveoli open
 Atelectasis

11. Mechanics of Respiration
 http://www.teachpe.com/anatomy/respiratory_system.php

12. Functional Residual Capacity
 Lung volume at end of
normal exhalation
 Muscles of
respiration are
completely
relaxed
 http://www.lakesidepress.com/pulmonary/htm

13. Gas Exchange
 http://www.uic.edu/classes/bios/bios100/lectures/circ.htm

14. Oxygenation
 Process of getting oxygen to end organs and
tissues
 Inhaled through lungs
 Picked up from alveoli on RBCs
 Off-loaded in exchange for CO2
 Measured by pulse oximetry (SpO2)
94%-100%

15. Ventilation
 Process to eliminate carbon dioxide (waste
product of energy production)
 Carried back through venous blood
 Eliminated through exhalation
 Measured by capnography

16. Respiratory
Disorders

17. Respiratory Disorders
A combination of many disease processes
responsible for emergencies related to
ventilation, diffusion and perfusion.

18. Respiratory Distress
 Subjective indication of some degree of
difficulty breathing
 Causes
 Upper or lower airway obstruction
 Inadequate ventilation
 Impaired respiratory muscle function
 Impaired nervous system
 Trauma
 Bronchitis, pneumonia, cancer

19. Respiratory Failure
 Clinical state of inadequate oxygenation, ventilation
or both.
 Often end-stage of respiratory distress
 Signs:
 Tachypnea (early)
 Bradypnea or apnea (late)
 Increased, decreased, or no respiratory effort
 Tachycardia (early)
 Bradycardia (late)
 Cyanosis
 Altered Mental Status

20. Mechanism of Heart Failure
 Frequently a chronic, yet manageable
condition
 Left ventricle fails to work as effective pump
(Left-Sided CHF)
 Blood volume backs up into pulmonary
circulation
 Most often caused by:
 Volume overload
 Pressure overload
 Loss of myocardial tissue

21. Pulmonary Edema
 Cardiac and respiratory system impairment
 Acute and critical emergency
 Filling of lungs with fluid
 Washes away surfactant
 Lipids & Proteins
 Prevents collapse of alveolus at low lung
volume
 Creates pink froth in sputum
 Prevents alveoli from expanding
 Significantly reduces or eliminates ability for gas
exchange to occur

22. Asthma
 Reactive airway disorder
 Exacerbation precipitated by extrinsic or
intrinsic factors
 Characterized by reversible bronchial smooth
muscle contraction, increased mucus
production and inflammatory airway changes
 Persistent signs and symptoms can indicate a
tenfold increase in the work of breathing

23. Asthma
 Evolution of asthma attack
 Mucus thickens and
accumulates plugging
airways
 Mucosal edema
develops
 Muscle spasms constrict
small airways
 Breathing becomes
labored
http://asthma-ppt.com/asthma-pictures.html

24. Caution
Asthma Anaphylaxis
Causes Smoke, dander, dust,
pollen, cold air, mold,
cleaning products,
perfume, exercise
Nuts, shellfish, milk, eggs, soy,
wheat, insect stings,
medications, latex
Symptoms Wheezing
Coughing
Shortness of breath
Difficulty breathing
Chest tightness
Face - itchiness, redness,
swelling of face & tongue
Airway – trouble breathing,
swallowing or speaking
Stomach – abdominal pain,
vomiting, diarrhea
Total hives, rash, itchiness,
swelling, weakness, pallor,
sense of doom, loss of
consciousness

25. Chronic Obstructive
Pulmonary Disease
 Obstructive lung disease
 Triad of distinct diseases that often coexist
 Asthma
 Chronic bronchitis
 Emphysema
 Traditionally refers to patients with
combination of chronic bronchitis and
emphysema

26. Chronic Bronchitis
 Bronchi become filled with excessive mucus
 Alveoli are not affected
 Diffusion of gas remains relatively normal
 Patients develop low oxygen pressures (PO2)
and hypoventilation
 Hypoventilation leads to high levels of CO2
and low levels of O2

27. Emphysema
 Results from
pathological changes in
the lung
 Permanent abnormal
enlargement of air
spaces beyond
terminal bronchioles
 Collapse of the
bronchioles
 Destruction of the
alveoli
 http://health.allrefer.com/health/chronic-obstructive-
pulmonary-disease-emphysema.html

28. Emphysema
 Patients have some
resistance to airflow,
primarily on exhalation
 Hyper-expansion
caused by air trapped
in the alveoli
 Breathing becomes an
active process
 Sanders, M.J. (2005) Paramedic Textbook (3rd
ed.) St.
Louis: Mosby-Elsevier

29. Emphysema
 Risk of pneumothorax
 Interior airway pressure
 CO2 Retention
 Potential worsening with CPAP

30. Continuous
Positive
Airway
Pressure

31. The use of CPAP prehospitally
reduces the need for intubation
by 30% and reduces mortality
by 20%
 Annals of Emergency Medicine, September 2008

32. CPAP
 Non-invasive ventilation
 Continuous O2
delivered at a set
positive pressure
throughout the
respiratory cycle
 www.ems1.com/cpap-for-ems

33. Positive Pressure
 PUSHES air into the chest
 Overcomes airway resistance
 Bag valve mask
 Demand valve
 Intubation / mechanical ventilation
 CPAP

34. Effects of CPAP
 Increases functional residual capacity
 Increases alveolar surface area available for
gas exchange
 Increases oxygen diffusion across alveolar
membranes
 Reduced work of breathing

35. Indications
 Severe Respiratory Distress / Respiratory
Failure
 Accessory muscle use?
 Persistent hypoxia despite appropriate /
aggressive oxygen therapy?
 Marked increased work of breathing?
 Inability to speak full sentences?
 Differentiate Pulmonary Edema versus other
Respiratory Disorder

36. Contraindications
 Respiratory rate < 10 breaths / minute
 Systolic blood pressure < 100 mmHg
 Confusion
 Inability to understand directions and
cooperate with application of CPAP
 History of pneumothorax
 History of recent tracheo-bronchial surgery
 Active nausea or vomiting
 Unconscious
 Facial Injuries

37. How CPAP Works
 Maintains constant level of airway pressure
 Keeps and maintains alveoli open.
 Moves fluid into vasculature (pulmonary edema)
 Improves gas exchange
 Buys time for medications to work

38. PEEP & Fi02
 Positive End-Expiratory Pressure
 The purpose of PEEP is to increase the volume of gas
remaining in the lungs at the end of expiration in order to
decrease the shunting of blood through the lungs and
improve gas exchange.
 Fraction of inspired oxygen
 The fraction or percentage of oxygen in the space being
measured.
 Natural air includes 20.9% oxygen, which is equivalent to
FiO2 of 0.21.
 Each additional liter of oxygen adds about 4% to their FiO2
Peep

39. Procedure
 Prepare C-PAP Equipment
 – Adjust FiO2 to 95%
 – Set PEEP at 5 cm H2O
 – Set O2 flow at (minimum 15 LPM)
 – Ensure adequate supply of oxygen (main
 and portable)
 Reassess patient every 5 minutes
 If patient continues to have severe
difficulty breathing after 5 minutes,
consider increasing PEEP to 10 cm
H2O

40. Limitations
 CPAP is not a mechanical ventilator
 Tight mask seal can create claustrophobic
response
 Consider allowing patient to self-seal (hold
own mask) until initial benefits recognized
 CPAP is powered by on-board oxygen supply

41. Oxygen Utilization
Cylinder
Flow
1000 PSI 1500 PSI 2000 PSI
D-15 LPM 8.5 min 13.8 min 19.2 min
D- 25 LPM 5.1 min 8.3 min 11.5 min
E- 15 LPM 14.9 min 24.3 min 33.6 min
E- 25 LPM 9 min 14.6 min 20.2 min
Cylinder
Flow
500 PSI 1000 PSI 1500 PSI
M- 15 LPM 31 min 83 min 135 min
M- 25 LPM 18 min 50 min 81 min
G- 15 LPM 48 min 129 min 209 min
G- 25 LPM 29 min 77 min 125 min

42. Summary
Pre-hospital studies have proven the
effectiveness of CPAP in treating patients
with severe respiratory distress, regardless of
disease process.

43. ANY
QUESTIONS

44. Practical
Skills
Session