CPAP can help patients with respiratory distress breathe easier by applying continuous positive airway pressure. It works by splinting open the airways and lungs to allow for better gas exchange and oxygenation of the blood. Studies show CPAP can reduce intubation rates, ICU admissions, and hospital lengths of stay for patients with pulmonary edema from heart failure and other respiratory conditions like pneumonia. While CPAP may not resolve the underlying problem, it can significantly improve symptoms and buy time to treat the condition further. Proper application and monitoring of patients on CPAP is important to watch for potential complications.

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

6. What is CPAP?Continuous Positive Airway Pressure

7. Why CPAPBetter for the patient Reduction in morbidity and mortalityLess invasive then intubationLess complications than intubationReduction in pre-hospital intubationReduction 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 MedicineBerstein, A. et al New England Journal of Medicine; 1991, 325:1825-183065% reduction in ED ETILin M, Yang TG, Chiang, et al Chest; 1995: 107:1379-8675% reduction in ICU ETIHastings, D., et al Journal of Emergency Medical Services; 1998 23(9):58-6585% reduction in PEC ETI50% reduction in ICU LOS Sacchetti, AD Harris, RH Postgraduate Medicine 1998 Feb;103 (2): 145-7, 153-4, 160-290% averted ETI in ED

10. MORE Studies Cincinnati EMS Mean LOS of 3.5 days for non ETI Mean LOS of 11 days for ETIGalveston EMSICU admission decreased 52%Avg LOS decreased from 14.8 to 8 days

12. Case Study #123:00 hours on a cool October eveningDifficulty breathing (6D1) BLS is 6 minutes & ALS is 11 minutes from the scene84 YOFCC: “Shortness of Breath”Increasing noctournaldyspnea for 3 days Tonight started to “choke on phlegm” and developed trouble breathing

13. Case STUDY #1Hx:CHF, HTNMeds:Lasix, Lisinopril, Coreg, Propoxyphene“Found in chair with moderate difficulty breathing on nasal O2 at 5lpm.”Initial Vital Sings: Pulse: 120Resp: 36BP: 158/PSpO2: 90%GCS: 15Lung Sounds: Bilateral RalesCPAP?

14. CASE STUDY #1BLS applies NRB @ 15 lpmThree minutes latter places patient on CPAP with 10 of PEEPALS arrives on scene and continues CPAPVital Signs 12 minutes post CPAP:Pulse: 104Resp: 32BP: 148/72SpO2: 97%GCS: 15Dx: Pulmonary Edema due to heart failure

15. Anatomy & Physiology Review

17. Respiratory Cycle Two Phases Inspiration Expiraton

18. InspirationActive process requiring muscles to have energy and function Diaphragm and intercostal muscles contractDiaphragm moves downwardRibs move upward and outwardIncreased chest size allows air to flow into the lungs (less pressure inside)

19. ExhalationPassive process allowing muscles to relaxDiaphragm rises Ribs moves downward and inward decreasing chest cavity sizeSmaller chest size allows air to flow out of the lungs (less pressure outside)

26. Four Chambers of the HeartLeft AtriumRight AtriumReceives blood from veins; pumps to right ventricle.Receives blood from lungs; pumps to left ventricle.Right VentricleLeft VentriclePumps blood through the aorta to the body.Pumps blood to the lungs.

27. ASSESSMENT & PHYSICAL EXAM

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

29. The ABC’S

30. VITALS SIGNSInterpreting Vital Signs Respirations SpO2PulseBlood Pressure SkinPhysical Exam Lung Sounds

31. RespirationsAdequate Respirations12-20Tidal Volume500ml at rest TachypneaHypoxia FeverPainBradypneaRespiratory failure Impending respiratory arrest

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

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

34. Blood PressureSystolic100-140 mmHgDiastolic60-90 mmHgHigh vs. Low

35. SkinColorNormal Pale Others TemperatureHotWarm CoolCold Condition DryMoist WetEdema

37. PITTING EDEMA

38. Lung SoundsNormalRales / CrackelsRhonchiWheezing Diminished

39. History

40. Clinical History Dyspnea at restDyspnea upon exertionOrthopneaParoxysmal Nocturnal DyspneaCough EdemaChest PainAbdominal DistentionDiaphoresis Anxiety Smothering sensation

41. Past Medical History CHF Atrial FibrillationLoss of atrial kick.MI DiabetiesRenal Failure Dialysis Alcohol use HypertensionHigh Cholesterol

42. Medications DirueticsLasixBumexACE InhibitorsCaptoprilEnalaprilLisinoprilCardiac GlycosidesDigoxinBeta Blockers The “olol” drugs Beware of masked tachycardia

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

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

45. Conditions that mimic CHF

46. COPDTriad of distinct diseases that often coexist: Chronic Bronchitis EmphysemaAsthma

47. Chronic BronchitisInflamatory changes and excessive mucous production in the bronchial treeCommonly caused by prolonged exposure to irritants

48. The “BLUE BLOATER”

49. EmphysemaCharacterized by: Permanent abnormal enlargement of the air spaces beyond the terminal bronchiolesDestruction of the alveoli Failure of the supporting structures to maintain alveolar integrityResults in:Reduced surface area Reduced elasticity, leading to air trapping Residual volume increases while vital capacity remains normal

50. The “PINK PUFFER”

51. AsthmaCommon chronic disorder of the airways that is complex and characterized by variable and recurring symptomsAsthma Triad: Increased mucous productionIncreased bronchial edemaBronchospasm

52. Asthma

53. PneumoniaInfection in the lung, specifically the alveoli

54. CPAP

55. What EXACTLY IS CPAP?

56. Where does CPAP FALL

57. PEEPPositive End Expiratory Pressurethe amount of pressure above atmospheric pressure present in the airway at the end of the respiratory cycleGoal of PEEP: Improve oxygenation Amount of PEEP: 5-10 cm H2OToo 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 doingIn 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 exchangeMaintain a positive pressure in the lungsMove some of the fluid out of the lungStops fluid from moving into the lungsOpen the alveoli to preventing collapseIncreasing the surface area in the alveoli will improve the gas exchange Increases intrathoracic pressureImproves cardiac output to a degreeToo Much PEEP decreases cardiac output

62. What will we see?In a perfect world: Improved gas exchangeDecreased anxiety Improved vital signsDecreased blood pressure Decreased pulse rateIncreased SpO2Improved respiratory effort Decreased respiratory rateDecreased 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 CPAPSome patient’s will require intubation

64. BUT WHAT HAPPENES TO THE FLUID?

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

66. Things we may seeGastric distention Corneal drying Hypotension PneumothoraxAnxiety

67. CPAP ConTraindicationsUnconscious Inability to protect airwayRespiratory Arrest Need for BVM or IntubationVomiting Facial traumaIncreased ICP (>20mmHg) – Unknown for us

68. Not a candidate for CPAP

71. Case Study #20028 hours “Interfacillity-Difficulty Breathing” 33C2BLS is 4 minutes & ALS is 10 minutes from the scene90 YOF CC: “shortness of breath” per the staffPer staff “sudden onset of shortness of breath Staff relates that the patient began to “choke” on something.

72. Case Study #2Hx:CHF, HTN, CVA, Atrial FibrillationMeds: Furosemide, Norvasc, Nitro, Coumadin, Digoxin“Found laying in bed with a simple mask and gurgling respirations”Initial Vital Signs:Pulse: 130Resp: 40 and shallowBP: 200/100GCS: 9Lung Sounds: Rale bilaterally BLS suctions the patient’s airwayWhen sitting the patient up, patient has snoring respirations. CPAP?

73. Case Study #2REMEMBER: Patient’s must have a self-maintained airway for CPAP applications. Airway managementNasal Oral PositioningIntubationManual positive pressure ventilations may be preferred with a BVM

74. CPAP DEVICES

76. Downs generator

77. Downs generatorRequires a high pressure oxygen source Requires a complete CPAP systemClosed systemEasily adjustable PEEP

78. Boussignac

79. BoussignacCurrently used for the NCC BLS Pilot Study.Low investment No additional equipmentCompletely Disposable As simple as applying a non-rebreatherSmall Size Open system Eliminates rebreathingAble to suction using a French catheter without losing pressureAllows use of a nebulizer

81. CPAP Os

82. CPAP OSHigh Cost for the system Requires a high pressure oxygen source Requires a complete CPAP systemClosed systemEasily adjustable PEEP with large guage

83. CareVENT

84. CareventHigh costOffers the best of both worlds Transport ventilator for intubated patientsCPAPRequires a high pressure oxygen source though consumes less oxygen in comparison to other modelsRequires a complete CPAP systemClosed system

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