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![Goal
The student will be able
to correctly utilize
service specific CPAP
devices in a respiratory
compromised patient
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Cpap final 2012_12 (2)
- 1. Continuous Positive Airway Pressure ForEMT Providers State Education & Training Committee December 2012
- 2. Goal The studentwill 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 thecompletion 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 ofRespiration
- 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 Respirationdriven 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 andcontract 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.
- 14. Oxygenation Process ofgetting 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 toeliminate carbon dioxide (waste product of energy production) Carried back through venous blood Eliminated through exhalation Measured by capnography
- 16.
- 17. Respiratory Disorders A combinationof many disease processes responsible for emergencies related to ventilation, diffusion and perfusion.
- 18. Respiratory Distress Subjectiveindication 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 Clinicalstate 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 HeartFailure 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 Cardiacand 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 airwaydisorder 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 ofasthma 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 Bronchibecome 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 pathologicalchanges 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 havesome 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 ofpneumothorax Interior airway pressure CO2 Retention Potential worsening with CPAP
- 30.
- 31. The use ofCPAP 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 PUSHESair 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 RespiratoryDistress / 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-PAPEquipment – 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 isnot 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 PSI1500 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 haveproven the effectiveness of CPAP in treating patients with severe respiratory distress, regardless of disease process.
- 43.
- 44.
Editor's Notes
- #6 Presenter should briefly review basic function of each component of respiratory tree Point out that while diaphragm is outside of the respiratory tree it is a functional unit of the respiratory process
- #7 Talking Points: The negative pressure that causes inhalation is created by chest expansion and contraction of the diaphragm. Knowledge Application: Have students describe the pressures of breathing. Discuss the role of both positive and negative pressure in moving air.
- #9 Regular contraction and relaxation of diaphragm and intercostal muscles results in negative pressure causing air to be drawn in to lungs Hemodynamic Effects Contraction of diaphragm and external intercostal muscles produces negative intrathoracic pressure Negative pressure engorges vena cava increasing cardiac preload Relaxation of diaphragm and contraction of intercostal and abdominal muscles produces positive pressure Positive pressure loads blood into the right atrium increasing Left Ventricular filling and cardiac output Process of inhalation stops when stretch receptors send signal via vagus nerve that pressure has equalized
- #10 In adults the trachea is about 2.5 cm (1 inch) in diameter and the smallest bronchioles are less than 0.5 mm (19 / 1,000th inch) in diameter Smooth muscle can constrict decreasing the internal diameter of bronchiole (bronchoconstriction) Bronchoconstriction can be protective against inhalation of potentially harmful substances but can become life threatening when airflow significantly decreased as in asthma
- #11 Adults have 300 to 600 million aveoli Adult lungs have between 50 to 100 square meters of alveoli surface area for gas exchange to occur Surfactant – phospholipids in a near-saline solution Phospholipids reduce surface tension of the saline making it easier for the lungs to expand and decreases work of breathing Atelectasis – decrease in amount of surfactant which allows for alveoli collapse
- #12 Inspiration (inhalation) is an active process where the intercostal muscles and diaphragm contract, expanding the size of the chest cavity and causing air to flow into the lungs Inspiration stops when stretch receptors in the lungs send a signal to the respiratory centers in the brain via the vagus nerve. Expiration (exhalation) is a passive process in which the intercostal muscles and diaphragm relax, causing the chest cavity to decrease in size and forcing air out of the lungs
- #13 At FRC ONLY the tendency of the lungs to collapse is exactly balanced by the tendency of the chest wall to expand In total, the lungs of an average sized adult hold about 5 - 6 L of air (Tidal volume of 500 ml x 10 – 12 breathes per minute) The volume of air moved in one inspiratory / expiratory cycle of breathing is called tidal volume. Multiply the tidal volume by the respiratory rate to determine minute volume, the amount of air that goes in and out of the lungs in 1 minute Minute volume can be effected by either tidal volume or rate, or both. Remember – not all of the minute volume air reaches the alveoli. Approximately 150 ml (in an average adult) occupies the space between the mouth and the alveoli but doesn’t reach the are of gas exchange. This is referred to as dead space volume Alveolar ventilation only occurs with air that actually reaches the alveoli
- #14 Principle of gas exchange within lungs Each alveolus is continually ventilated with fresh air Respiratory membrane is composed of alveolar wall (fluid coating, epithelial cells, and basement membrane), interstitial fluid, and the wall of a pulmonary capillary (basement membrane and endothelial cells). Gases (oxygen and carbon dioxide) diffuse across the respiratory membrane.
- #15 Pulse oximetry measures percentage of hemoglobin molecules that are bound in arterial blood provides an indirect indication of oxygenation in the blood Reliable down to approximately 85% Accuracy of reading effected by adequate amounts of hemoglobin in blood, and total blood volume Pulse oximetry does NOT measure partial pressure of oxygen or carbon dioxide in plasma
- #19 Unlike respiratory failure, patients in respiratory distress are able to maintain near-normal blood gas levels and oxygenation Occurs anytime that the body’s need for oxygen exceeds its ability to deliver oxygen Most patients in respiratory distress have dyspnea. CC – I can’t catch my breath or shortness of breath VS – changes in rate, regularity, depth and / or effort of breathing
- #21 Effect approximately 5 million Americans and is responsible for 7,000 to 10,000 hospital admission each year Blood volume is delivered to but not fully ejected left ventricle Increase in end-diastolic blood volume increases left ventricular end-diastolic pressure. Pressure is transferred to left atrium and then to pulmonary capillaries and veins As pulmonary capillary pressure increases, plasma portion of blood is forced into alveoli
- #22 Can have rapid onset or be a by-product of untreated or poorly treated heart failure Filling of lungs with fluid – pulmonary edema occurs because of the accumulation of extravascular fluid in the lungs and alveoli Cardiac pulmonary edema — also known as congestive heart failure — occurs when the diseased or overworked left ventricle isn&apos;t able to pump out enough of the blood it receives from your lungs. As a result, pressure increases inside the left atrium and then in the veins and capillaries in your lungs, causing fluid to be pushed through the capillary walls into the air sacs. Fluid may also leak from the capillaries in your lungs&apos; air sacs because the capillaries themselves become more permeable or leaky, even without the buildup of back pressure from your heart. In that case, the condition is known as noncardiac pulmonary edema because your heart isn&apos;t the cause of the problem Patients present with severe dyspnea, agitation (b/o hypoxia), crackles (frequently audible w/o stethoscope), JVD, significantly increased B/P, rapid labored respirations Emergency management directed at decreasing venous return to the heart, improving myocardial contractility, decreasing myocardial oxygen demand, improving ventilation and oxygenation and rapid transport Prior to pre-hospital CPAP, could frequently result in endotracheal intubation
- #23 Common disorder affecting 10 to 15 million Americans (4 – 5% of total US population) Responsible for 4,000 – 5,000 deaths per year Most common in children and young adults; can occur in any decade of life Childhood asthma tends to improve or resolve with age Adult onset asthma is usually persistent disorder Exacerbation is an aggravation or increase the severity of underlying symptoms Extrinsic (external) factors usually involved inhaled allergen, pollen or dander which sensitizes bronchial mucosa by tissue-specific antibodies Intrinsic (internal) factors are more related to viral infections, physical exertion, aspirin use, smoke, fumes or stress which will trigger either increased release of acetylcholine or release of chemical mediators from mast cells. Whether extrinsic or intrinsic, the end product of these stimuli is bronchoconstriction
- #25 Anaphylaxis can frequently mimic asthma EMTs must be able to differentiate the cause of symptoms Regardless of the cause, airway management must be the highest priority of patient care
- #26 Affect more than 17 million Americans Predisposing factors – smoking, environmental pollutants, industrial exposures, various pulmonary infectious disease processes
- #27 Affects about 20% of men in US Diagnosed by presence of cough with sputum production on most days for at least 3 months of the year for 2 consecutive years
- #28 Emphysema is the end stage of a process the progresses slowly for years. Emphysema decreases the number of alveoli for gas exchange and reduces the elasticity of remaining alveoli resulting in trapping of air within the alveoli. Therefore, residual volume (the volume of air remaining in the lungs after a maximal exhalation) increases while vital capacity (the volume in the lungs at maximal inflation minus Residual volume) remains normal Decreases in alveolar capillaries in the lung reduces the area for gas exchange and increases resistance to pulmonary bloodflow
- #29 Patients with emphysema find they can breathe better of exhaling against resistance. They make this resistance by pursing their lips. Over time, the chest becomes rigid (barrel shaped) requiring use of accessory muscles of neck, chest and abdomen to move air into and out of lungs. Full deflation of lungs becomes more and more difficult and finally impossible
- #30 Patients with emphysema often develop bullae or blebs (thin-walled cystic lesions in the lungs) from the destruction of the alveolar walls. When the blebs collapse, they increase the problems with air exchange seen in these patients. They can also lead to pneumothorax. Pressure is evenly distributed throughout the closed (respiratory) system. If lung tissue has a weakness, or ventilatory pressures are too high, the lungs can become over pressurized. Pulmonary over pressurization can cause a pneumothorax, pneumo-mediastinum, subcutaneous emphysema or tension pneumothorax CO2 retention is a pathophysiological process in which too little carbon dioxide is removed from the blood by the lungs. The end result is an elevated level of carbon dioxide (hypercapnia) dissolved in the bloodstream. The principal result of the increased amount of dissolved CO2 is respiratory acidosis. CO2 retention is a problem in various respiratory diseases, particularly (COPD). Patients with COPD who receive excessive supplemental oxygen can develop CO2 retention, and subsequent hypercapnia. The mechanism that underlies this state is a matter of controversy. Some authorities point to a reduction in the hypoxic &quot;drive&quot;, a condition called carbon dioxide narcosis. When carbon dioxide levels are chronically elevated, the respiratory center becomes less sensitive to CO2 as a stimulant of the respiratory drive, and the PaO2 provides the primary stimulus for respirations. Administering excess supplemental oxygen can potentially suppress the respiratory center. However, it is unclear whether such a hypoxic drive exists in the first place. An alternative explanation is that, in patients with COPD, the administration of oxygen leads to an increase in the degree to which diseased alveoli are perfused with blood relative to other, less-diseased alveoli. As a result, a larger fraction of blood passes through parts of the lung that are poorly-ventilated, with a resulting increase in the CO2 concentration of the blood leaving the lungs. As CO2 levels increase, patients exhibit a reduction in overall level of consciousness as well as respiratory effort. Severe increases in CO2 levels can lead to respiratory arrest. Providers need to be aware that administration of CPAP with associated high concentration oxygen has the potential to create a worsening of patient condition in CO2 retainers rather than improving it.
- #32 Research has proven the benefits of utilizing CPAP in the pre-hospital setting on patient outcomes.
- #33 CPAP provides high pressure oxygen delivered via mask under continuous pressure. This wall of air creates pneumatic splinting of airways and creates a backpressure to keep small airways and alveoli open. Patients are now breathing against a threshold of resistance
- #34 At rest respiration if a function of negative pressure which pulls air into the chest Nasal canula, non-rebreather masks and nebulizers function within a system of negative pressure inspiration.
- #35 Positive pressure simply puts more air into the lungs By preventing atelectasis (collapse of alveoli) more alveoli are available for gas exchange Pressure pushed the oxygen to distal airway structures The pneumatic splint of CPAP prevents the patient from having to exert energy themselves to breathe.
- #36 While initially indicated only for patients with CHF / pulmonary edema, pre-hospital CPAP is now appropriate for use on patients with acute blunt pulmonary trauma and those with obstructive pulmonary diseases. In a 2003 Helsinki EMS study using only patients with Acute Pulmonary edema, patients had a noted improvement after CPAP administration even though there was a high misdiagnosis rate (84/121). Kallio, T. et al. Prehospital Emergency Care. 2003. 7(2) If patients meet indication inclusion criteria, DO NOT worry about specifically which Respiratory disorder you are treating with CPAP CPAP should be initiated regardless of length of transport time
- #37 Effective use of the device requires a patent airway and intact respiratory effort If patients do not qualify for NTG because of low BP, they do not qualify for CPAP either Positive pressure in the chest can impact filling of the heart (pre-load) and cause a subsequent drop in BP CPAP is an active process requiring patient cooperation and participation Increased intra-thoracic pressure increases the risk for pneumothoraces and / or tracheo-bronchial rupture in susceptible patients Emesis in patients with severe respiratory compromise may require aggressive airway management to prevent aspiration
- #38 Unlike BiPAP which delivers two levels of pressure (high inspiratory Positive Airway Pressure and a lower Expiratory Positive Airway Pressure), CPAP delivers a predetermined high level of pressure. CPAP overcomes constricted airway resistances and increases airflow Fluid in the alveoli inhibits gas exchange. CPAP moves fluid back into vasculature decreasing fluid overload and work of breathing By overcoming airway resistance CPAP keeps alveoli open and allows for improved and increased gas exchange Nitro spray or mist, utilized prior to CPAP, produces peripheral vasodilation, decreases cardiac preload and reduces fluid overload and pulmonary edema If equipment allows, in-line nebulized bronchodilators can be administered while patient on CPAP CPAP works adjunctively with medications to produce desired effects Lasix, given in conjunction with Nitroglycerine and CPAP results in elimination of excess fluid through increased urination. Lasix is no longer used as a pre-hospital treatment in some regions of Connecticut
- #39 https://www.youtube.com/watch?v=iuUSDR4ocCY
- #41 Any patient requiring aggressive airway management and mechanical ventilation are not candidates for CPAP. Airway pressure is maintained through use of PEEP when patients are mechanically ventilated Patients may self-exclude themselves from CPAP use because of claustrophobia. DO NOT FORCE THE MASK SEAL ON THESE PATIENTS – ANXIETY WILL WORSEN THEIR RESPIRATORY DISTRESS CPAP creates a huge oxygen source demand and can deplete O2 reserves during long transports
- #42 Changes in pressure dynamics create patient improvement – NOT O2 CPAP units can be run on medical air – pressure exertion creates PEEP not O2 use If allowed by medical control, patients on CPAP should have concomitant SPO2 monitoring As CPAP comes in to use, it becomes even more globally important to maintain oxygen resources in vehicles, especially in services with long transport times. Stated values are averages for several different CPAP units but are not correct for all CPAP. Individual CPAP units can have different oxygen requirements and therefore, will impact how long oxygen sources will last. Each agency will follow medical direction protocols for individualized oxygen parameters
- #43 While CPAP should not be the first line of treatment in patients with Severe Respiratory Distress, in conjunction with pharmacology the benefits of incorporating its use cannot be disputed.