This document provides an overview of CPAP training for paramedics. It covers the background and history of CPAP, physiology of how CPAP works, indications and contraindications for its use, administration procedures, potential complications, documentation requirements, and considerations for EMS systems implementing CPAP protocols. Key points emphasized include starting CPAP at low pressures and titrating upward, using it primarily for CHF/APE but also for respiratory failure from other causes, and being prepared to intubate if the patient does not improve or their condition deteriorates on CPAP.

1. State of Idaho CPAP training Module DRAFT

2. Revision Information Developed October 2008 Revised November 2008 For Further Information Please contact: Instructor contact information

3. Introduction Instructor Introduction Experience Conflicts of interest Device to be used for this training This presentation was developed at the direction of the State of Idaho, Department of Health and Welfare, Bureau of EMS

4. Special Thanks The Men and Women of Ada County Paramedics for their input, advice, and good sportsmanship in developing this presentation www.adaparamedics.com State of Maine EMS State of Wisconsin EMS

5. CPAP - Background Continuous Positive Airway Pressure (CPAP) and related technologies have been in use for since the 1940’ in respiratory failure. It has been largely indicated to assist patients with primary and secondary sleep apnea, and globally this continues to be its largest market. In recent history (1980’s) it has found wide acceptance in hospital settings (usually CCU, ICU, and ERs) for patients suffering varying degrees of respiratory failure of a wide variety of origins. Acute Pulmonary Edema (APE) most common

6. CPAP - Background CPAP is a non-invasive procedure that is easily applied in the pre-hospital setting. CPAP is an established therapeutic modality, well studied to reduce both mortality and morbidity. CPAP has been shown to be an preferable alternative to intubation in some patients.

7. History of CPAP 1912 - Maintenance of lung expansion during thoracic surgery (S. Brunnel) 1937 - High altitude flying to prevent hypoxemia. (Barach et al) 1967 - CPPB + IPPV to treat ARDS (Ashbaugh et al) 1971 - Term CPAP introduced, used to treat HMD in neonates (Gregory et al) 1972 - CPAP used to treat ARF (Civetta et al) 1973 - CPAP used to treat COPD (Barach et al) 1981 - Downs generator (Fried et al) 1982 - Modern definition of CPAP (Kielty et al)

8. Boussignac CPAP? 1973- Boeing 707 crashed near Paris France 125 fatalities, 3 survivors with severe respiratory trauma CPAP was not well known at the time. Mortality for these injuries was 100% Dr. Georges Boussignac, decided not to intubate these patients but to treat them instead with Non Invasive Ventilation (NIV) and an early form of CPAP. The original CPAP was a bag over the head with constant air flow at greater than atmospheric pressure.

9. Types of CPAP

10. Boussignac

11. Oxypeep

12. Whisperflow Flow Generators

13. Emergent Products PortO2vent

14. CAREvent® ALS + CPAP

15. Physiology of CPAP

16. Vital Terminology Tidal Volume (Vt) Minute Volume (Vm) Peak Inspiratory Flow Functional Reserve Capacity (FRC) Inspired Oxygen (FiO2) Work of Breathing (WOB)

18. Airway and Respiratory Anatomy and Physiology Pathway review Oxygenation and Ventilation Functional Residual Capacity Work of breathing

19. Airway and Respiratory Anatomy Pathways-

20. Airway and Respiratory Anatomy Pathways-

21. Question: So why does oxygen pass into the blood? A: The Pressure Gradient!!!! Airway and Respiratory Physiology

22. Airway and Respiratory Physiology The Pressure gradient! Aveolar Air has higher content of OXYGEN than venous (deoxygenated) blood Therefore oxygen transfers from the air into the blood. This is called the Pressure Gradient The higher the inspired oxygen (FiO2) the better the pressure gradient!

23. Airway and Respiratory Physiology Oxygen Saturation Curve Picture released into public domain by wikipedia

24. Airway and Respiratory Physiology FRC Functional reserve Capacity (FRC) is the volume of air in the lungs at the end of a normal passive expiration. approximately 2400 ml in a 70 kg, average-sized male FRC decreases with lying supine, obesity, pregnancy and anaesthesia. Important aim of CPAP is to increase functional residual capacity (FRC) By increasing he FRC, the surface area of the Aveoli is distended ( increased ). Greater surface area improves gas exchange (oxygenation and ventilation) This improves Spo2/SaO2

25. Airway and Respiratory Physiology WOB Work of breathing (WOB) is respiratory effort to effect oxygenation and ventilation. Important aim of CPAP is to reduce work of breathing (WOB)

26. Airway and Respiratory Physiology WOB Signs of increased WOB: Dyspnea on Exertion (DOE) Speech Dyspnea Tripoding Orthopnea Accessory Muscle Use/Restractions Lung Sounds “ Doorway Test” Silent Chest!!!!

27. Airway and Respiratory Physiology WOB Increased WOB : Respiratory Fatigue Respiratory Distress Respiratory Failure CPAP reduces WOB

28. Airway and Respiratory Pathology

29. Airway and Respiratory Pathology CHF Precipitating Causes Non Compliance with Meds and Diet Acute MI Arrhythmia (e.g. AF) Increased Sodium Diet (Holiday Failure) Pregnancy (PIH, Pre-eclampsia, Eclampsia)

30. Airway and Respiratory Pathology CHF Severe resp distress Foamy blood tinged sputum Accessory muscle use Apprehension, agitation Speech Dyspnea Diaphoresis Bilateral crackles or Rhales Orthopnea (can’t lie down) Paroxysmal nocturnal dyspnea (PND) Cyanosis Pedal Edema JVD Chest pain (possible co-existent AMI) abnormal vitals (increased B/P; rapid pulse; rapid & labored respirations

31. Cardiac Asthma? Fluid leaks into the Interstitial Space Airways narrow Mimics broncoconstriction seen in asthma May actually exacerbate asthma if a co-existing PMHx Produces “Wheezing”

32. Infiltration of Interstitial Space Normal Micro-anatomy Micro-anatomy with fluid movement.

33. Airway and Respiratory Pathology CHF The following treatments should be done concurrently with CPAP, patient condition permitting*. High Flow Oxygen!!! Nitroglycerin * 0.4 mg sl every 5 minutes; 0.5-2 inches transdermal 5-200 mcg/min IV Drip Lasix * 20- 80 mg IV/IM (or double daily dose if already on Lasix) Opiates* Reduce Anxiety Mild Vasodilator 2.5-5 mg q5 minutes IVP (* = defer to local protocol or medical control)

34. Airway and Respiratory Pathology Asthma and COPD Obstructive vs Reactive airways Bronchoconstrictive issues Poor Gas Exchange Accessory Muscle Use/Muscle Tiring CPAP is best reserved for those patients who are refractory to normal interventions, and have a severe presentation. At least TWO doses of bronchedialtors should be administered before the provider initiates CPAP.

35. Airway and Respiratory Pathology Asthma and COPD The following treatments should be done concurrently with CPAP, patient condition permitting*. High Flow Oxygen!!! Bronchodilators* Albuterol 2.5 mg (0.83% in 3 cc)/ Atrovent 0.5 mg (0.02% in 2.5 cc) nebulized. Repeat as needed with Albuterol Only. Do not dilute. Magnesium Sulfate* (Asthma extremis only) IV: 2 g given SLOWLY, diluted. Do not give faster than 1 g/minute. Epinephrine 1:1,1000 0.3-0.5 mg IM/SQ for severe refractory bronchospasm Use Epinephrine with caution on patients over 65 or with cardiac history. Solu-medrol IV/IM: 125 mg (* = defer to local protocol or medical control)

36. Airway and Respiratory Pathology Pneumonia Infectious process Often confused with, or masked by, CHF Detailed assessment required PMhx, Med list review Sputum type/color Onset of s/s Fever Lack of CHF/Afib Hx Normal CHF Tx may be ineffective or detrimental Nitroglycerine (ineffective) Diuretics (detrimental)

37. Airway and Respiratory Pathology Pneumonia CPAP may be of minimal benefit in Pneumonia*. High Flow Oxygen!!! Bronchodilators* Albuterol 2.5 mg (0.83% in 3 cc)/ Atrovent 0.5 mg (0.02% in 2.5 cc) nebulized. Repeat as needed with Albuterol Only. Do not dilute. (* = defer to local protocol or medical control)

38. Airway and Respiratory Pathology Drowning CPAP may be beneficial to the drowning/near drowning patient Strongly consider intubation for severe s/s refractory to CPAP and other treatments

39. Other uses of CPAP ARDS Acute Respiratory Failure Anesthesia (Pre-Op and Post-Op) Atelectasis Alternative to Mechanical Ventilation Weaning from Mechanical Ventilation Left Ventricular Failure Renal Failure Sleep Apnea

40. Physiology of CPAP

41. Physiology of CPAP Airway pressure maintained at set level throughout inspiration and expiration Maintains patency of small airways and alveoli “ Stents” small airways open “ Distends” aveoli Improves delivery of bronchodilators By up to 80% Moves extracellular fluid into vasculature Improves gas exchange Reduces work of breathing

42. Physiology of CPAP : CPAP Mechanism Increases pressure within airway. Airways at risk for collapse from excess fluid are stented open. Gas exchange is maintained Increased work of breathing is minimized

43. Physiology of CPAP : Redistribution of pulmonary edema with CPAP

44. Physiology of CPAP: Hypotension CPAP increases intrathoracic pressure This decreases cardiac output causing hypotension Therefore hypotensive patients may have are relatively contraindicated with CPAP...

45. Physiology of CPAP : Administration of Medications by CPAP CPAP and Nebulizers can be used together to provide better “penetration” of nebulizer medications through the respiratory tract.

46. Use of CPAP by EMS

47. Goals of CPAP use in the field Primary Goals Increase amount of inspired oxygen (FiO2) Increase the SpO2 and PaO2 of the patient Decrease the work load of breathing (WOB) To reduce overall mortality Secondary Goals: Reduce the need for emergent intubations of the patient Decrease hospital length of stay (LOS)

48. CPAP vs. Intubation CPAP Non-invasive Easily discontinued Easily adjusted Use by EMT-B (in some states) Minimal complications Does not (typically) require sedation Comfortable Intubation Invasive Intubated stays intubated Requires highly trained personnel Significant complications Can require sedation or RSI Potential for infection

49. Key Point: This module discusses CPAP in patients >8 years of age CPAP has been safely used in children, infants, and neonates in the in-hospital and critical care settings Local protocols may allow use in children and infants Appropriate sized equipment mandatory Risk increases Consult medical control and local protocols

50. Indications For consideration (for patients <8) in moderate to severe respiratory distress secondary to: CHF/APE Acute Respiratory Failure asthma/reactive airway disease, near drowning, COPD, acute pulmonary edema (cardiogenic and non cardiogenic), pneumonia who present with any of the following: Pulse oximetry < 88% not improving with standard therapy ETCO2 > 50mmHg Accessory muscle use / retractions Respiratory rate > 25 Wheezes, rales, rhonchi Signs of respiratory fatigue or failure

51. A note on misdiagnosis There is a significant misdiagnosis rate of CHF in the field, most commonly confused with pneumonia CPAP still demonstrated significant improvement in other (non-CHF/APE) respiratory emergencies Risks are greater in non CHF/APE CPAP Max Pressures are lower non CHF/APE Caution is required non CHF/APE

52. 2003 Helsinki EMS Looked at “patients in Acute Severe Pulmonary Edema (ASPE)” Study Group: 121 Confirmed CHF: 38 (32%) Miss- DX: 83 (68%) Non CHF Patients that got better with CPAP : 34 (28%) Non CPAP mortality (17.8%) CPAP Mortality (8%) Other Notes: Confirmed by MNP Treated with Low-Mid FiO2, Nitrates. No Lasix 4 intubated in field (3%) (Kallio, T. et al. Prehospital Emergency Care. 2003. 7(2) )

53. Contraindications/Exclusion Criteria Physiologic Unconscious, Unresponsive, or inability to protect airway. Inability to sit up Respiratory arrest or agonal respirations (Consider Intubation) Persistent nausea/vomiting Hypotension- Systolic Blood Pressure less than 90 mmHg Inability to obtain a good mask seal Pathologic Suspected Pneumothorax Shock associated with cardiac insufficiency Penetrating chest trauma Facial anomalies /trauma/burns Closed Head Injury Has active upper GI bleeding or history of recent gastric surgery Vomiting

54. Cautions History of Pulmonary Fibrosis Claustrophobia or unable to tolerate mask (after initial 1-2 minutes) Coaching essential Consider mild sedation Has failed at past attempts at noninvasive ventilation Complains of nausea or vomiting Has excessive secretions Has a facial deformity that prevents the use of CPAP

55. Administration CPAP is measured in cm/H2O Start with device in the lowest setting, and titrate upward. Initial dose at 0-2 cm/H2O Titrated up to*: 10 cm/H2O MAX for CHF or, 5 cm/H2O MAX for COPD, near drowning, and respiratory failure form other causes. (* = defer to local protocol or medical control)

56. Selling CPAP? Placing CPAP is an anxiety inducing event in the hypoxic respiratory distressed patient! Verbally calming, coaching, and preparing (AKA: Selling) your patient on CPAP is essential Similar to calming a hyperventilation patient

57. Complications CPAP may drop BP due to increased intrathoracic pressure. A patient must have a systolic BP of at least 90mmHg to be a candidate for CPAP Increased Intrathoracic pressure means decreased ventricular filling and increased afterload, thus decreasing cardiac output and blood pressure. Providers should be comfortable giving a CPAP patient NTG If they are too hypotensive for NTG, then they are too hypotensive for CPAP. Risk of pneumothorax Increased intrathoracic pressure = increased risk Higher in Asthmatics and COPD Gastric Distention, and vomiting Strongly consider placement of a gastric tube (if in scope of practice) Risk of corneal drying High volumes of air blowing at eyes, especially on long transports.

58. Discontinuing of CPAP CPAP therapy needs to be continuous and should not be removed unless the patient: cannot tolerate the mask, success of tolerance to the treatment increased with proper coaching by EMS crew requires suctioning or airway intervention, experiences continued or worsening respiratory failure, Develops severe hypotension or a pneumothorax is suspected. Intermittent positive pressure ventilation and/or intubation should be considered if patient is removed from CPAP therapy.

59. KEY POINT: CPAP will not cure all patients! Some patients just really want a tube! “ Don’t give up to early but know when to give up”

60. Documentation “ Dosage” CPAP level  (10cmH2O) FiO2  (100%) Subjective response to therapy Objective response to therapy Lung Sounds, Work of Breathing SPO2 Nasal ETCO2 SpO2 q5 minutes Vital Sign q5 minutes Any adverse reactions Justification for sedation, intubation, or discontinuation of CPAP. Be specific.

61. Documentation: Modified Borg Scale “ 0”-No breathlessness at all “ 1”-Very slight “ 2”-Slight breathlessness “ 3”-Moderate “ 4”-Somewhat severe “ 5”-Severe “ 7”-Very severe “ 9”-Very, very severe (Almost maximum) “ 10”-Maximum

62. EMS System Implementations and Considerations Types of CPAP Oxygen source and supply Size of tanks Availability of “full” tanks Availability of appropriate regulators Duration of transport Destination Hospital Turnaround time and transfer of care

63. CPAP and Intubation Intubation will be inevitable in some patients regardless of the use of CPAP, and the paramedic must be prepared for rapid intervention by RSI/MAI or other means as feasible. Indications to proceed to ET placement are (not all inclusive): Deterioration of mental status Increase of the EtCO2 Decline of SpO2 Progressive fatigue Ineffective tidal volume Respiratory or cardiac arrest.

64. POST POST does not specifically address CPAP, but is likely permissible since it is both palliative and noninvasive.

65. Research Review

66. Research Review JAMA December 28, 2005 “Noninvasive Ventilation in Acute Cardiogenic Edema”, Massip et. al. Meta-analysis of studies with good to excellent data 45% reduction in mortality 60% reduction in need to intubate

67. Research Review CPAP therapy can improve A.P.E. patients in Minutes. Has been compared to D50 in hypoglycemic patients “ CPAP was associated a decrease in need for intubation (-26%) and a trend to a decrease in hospital mortality (-6%) compared with standard therapy alone.” (Pang, D. et al. 1998. Data review 1983-1997. Chest 1998; 114(4):1185-1192) 2000 Cincinnati EMS looked at “CHF patients in imminent need of intubation” 19 patients included, CPAP administered *Pre- and post-therapy pulse ox increased from 83.3% to 95.4% *None of the patients were intubated in the field *Average hospital stay reduced from 11 days to 3.5 days

68. “ CPAP is to APE like D50 is to insulin shock” - Russell K. Miller Jr, MD, FACEP

69. Research Review CPAP in COPD: 85 patients in a single ICU over a study period. Randomized control group CPAP significantly reduced need of ETT in COPD patients by 48% Complications were decreased by 32% Mortality Decreased by 20% “ CONCLUSIONS. In selected patients with acute exacerbations of chronic obstructive pulmonary disease, noninvasive ventilation can reduce the need for endotracheal intubation, the length of the hospital stay, and the in-hospital mortality rate. “ Brochard L, Mancebo J, Wysocki M, Lofaso F, Conti G, Rauss A, Simonneau G, Benito S, Gasparetto A, Lemaire F, et al Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease . N Engl J Med 1996;334(11):743. .

70. Research Review BiPap vs. CPAP “ Though BLPAP (BiPAP) has theoretical advantages over CPAP, there are questions regarding its safety in a setting of CHF. The Key to success in using NIV to treat severe CHF is proper patient selection, close patient monitoring, proper application of the technology, and objective therapeutic goals. When used appropriately, NIV can be a useful adjunct in the treatment of a subset of patients with acute CHF at risk for endotracheal intubation.” Reviews in Cardiovascular Medicine, vol. 3 supl. 4 2002, “Role of Noninvasive Ventilation in the Management of Acutely Decompensated Heart Failure”

71. Research Review: BiPAP vs CPAP European Respiratory Journal, vol. 15 2000 “Effects of biphasic positive airway pressure in patients with chronic obstructive lung disease” BiPAP resulted in overall higher intrathoracic pressures – reduces myocardial perfusion BiPAP resulted in lower tidal volumes BiPAP resulted in higher WOB

72. Research review: Pre-hospital CPAP PEC 2000 NAEMSP Abstract, “Pre-hospital use of CPAP for presumed pulmonary edema: a preliminary case series”, Kosowsky, et. al. 19 patients Mean duration of therapy 15.5 minutes Oxygen sat. rose from 83.3% to 95.4% None were intubated in the field 2 intubated in the ED 5 subsequently intubated in hospital “ Pre-hospital CPAP is feasible and may avert the need for intubation”

73. Review CPAP is not a substitute for patients needing IPPV or intubation. CPAP works best when used in conjunction with other therapies. CPAP doses start at ZERO and titrate up Max of 10 cmH2O for APE Mac of 5 cmH2O for other causes CPAP is effective in COPD when CAREFULLY used.

74. Key Points of CPAP CPAP, while very beneficial in many patients, is not risk free . Pneumothorax Regurgitation and aspiration hypotension

75. Review local protocol or local Medical Director considerations

76. Questions?

77. Device specific orientation and skills practice Followed by skills check off and a written test!