Slide 1

Continuous Positive Airway Pressure (CPAP) Washington State Department of Health EMT Basic Curriculum Developed by: Lynn Wittwer, MD, MPD Marc Muhr, EMT-P TJ Bishop, EMT-P Clark County EMS Keith Wesley, MD, EMS Medical Director State of Wisconsin Slide 2 Washington EMT-B CPAP Curriculum2 CPAP Curriculum EMT Basic Introduction Review of Anatomy and Physiology CPAP Overview Pulse Oximetry Review of Respiratory Distress Treatment With CPAP Slide 3 Washington EMT-B CPAP Curriculum3 What is CPAP? Continuous Positive Airway Pressure (CPAP) A non-invasive alternative to intubation Does not require any sedation It provides comfort to the patient with acute respiratory distress by reducing work of breathing Slide 4 Washington EMT-B CPAP Curriculum4 Why CPAP? Respiratory Distress is a common reason why people call 911! Established therapeutic alternative Easily applied, easily discontinued Slide 5 Washington EMT-B CPAP Curriculum5 Key Points of CPAP CPAP has been successfully demonstrated as an effective adjunct in the management of a variety of respiratory distress states. CPAP may prove to be a viable alternative in many patients previously requiring endotracheal intubation by prehospital personnel. Slide 6 Washington EMT-B CPAP Curriculum6 CPAP vs. Intubation CPAP Non-invasive Easily discontinued Easily adjusted Use by EMT-B Does not require sedation Comfortable Intubation Invasive Usually dont extubate in field Potential for infection Requires highly trained personnel Can require sedation Traumatic Slide 7 Review of Anatomy & Physiology Slide 8 Washington EMT-B CPAP Curriculum8 Elements of the Airway UPPER AIRWAY NaresNasopharynxOropharynxTongueEpiglottis/Glottis Vocal Cords LOWER AIRWAY Trachea/EsophagusCarina Main stem Bronchi Secondary Bronchi BronchiolesAlveoli Slide 9 Washington EMT-B CPAP Curriculum9 Upper Airway Slide 10 Washington EMT-B CPAP Curriculum10 Pharynx Pharynx Nasopharynx Uppermost portion of airway, just behind nasal cavities Nasal septum Vestibule Olfactory membranes Sinuses Oropharynx Begins at the level of the uvula and extends down to the epiglottis Opens into the oral cavity Slide 11 Washington EMT-B CPAP Curriculum11 Larynx Three main functions: Air passageway between the pharynx and lungs Prevents solids and liquids from entering the respiratory tree Involved in speech production Slide 12 Washington EMT-B CPAP Curriculum12 Larynx An outer casing of nine cartilages Thyroid cartilage Cricoid cartilage Only complete cartilaginous ring in the larynx Epiglottis Hyoid bone Cricothyroid membrane Vocal cords Slide 13 Washington EMT-B CPAP Curriculum13 Lower Airway Slide 14 Washington EMT-B CPAP Curriculum14 Slide 15 Washington EMT-B CPAP Curriculum15 Lungs Principal function is respiration Attached to heart by pulmonary arteries and veins Separated by mediastinum and its contents Base of each lung rests on the diaphragm Apex extends 2.5 cm above each clavicle Slide 16 Washington EMT-B CPAP Curriculum16 Pleural Cavity A separate pleural cavity surrounds each lung Two layers (visceral and parietal) Pleural space Slide 17 Washington EMT-B CPAP Curriculum17 Respiratory System - Physiology The respiratory system functions as a gas exchange system Oxygen is diffused into the bloodstream for use in cellular metabolism Slide 18 Washington EMT-B CPAP Curriculum18 Respiratory System - Physiology Wastes, including carbon dioxide, are excreted from the body via the respiratory system Slide 19 Washington EMT-B CPAP Curriculum19 Ventilation Ventilation refers to the process of air movement in and out of the lungs The volume of air moved in each breath is the tidal volume The volume still remaining in the chest after exhalation is the functional reserve capacity. FRC Slide 20 Washington EMT-B CPAP Curriculum20 Inspiration and Expiration Inspiration Chest wall expands Lung space increases Pressure gradient causes gas to flow into the lungs Expiration Chest wall relaxes Elastic recoil causes thorax and lung space to decrease in size Pressure gradient created in thoracic cavity causes air to move out of the chest Slide 21 Washington EMT-B CPAP Curriculum21 Pressure Changes During Inspiration and Expiration Slide 22 Washington EMT-B CPAP Curriculum22 Mechanics of Breathing Slide 23 Washington EMT-B CPAP Curriculum23 Mechanics of Respiration Slide 24 Washington EMT-B CPAP Curriculum24 Ventilation The following must be intact for ventilation to occur: Neurologic control to initiate ventilation Nerves between the brainstem and the muscles of respiration Functional diaphragm and intercostal muscles A patent upper airway A functional lower airway Alveoli that are functional and not collapsed Slide 25 Washington EMT-B CPAP Curriculum25 Diffusion In order for diffusion to occur, the following must be intact: Alveolar and capillary walls that are not thickened Interstitial space between the alveoli and capillary wall that is not enlarged or filled with fluid Slide 26 Washington EMT-B CPAP Curriculum26 How does CPAP work Splints the upper airway preventing collapse Uses continuous oxygen flow with pressure to push air into the lungs and push the fluid into the bloodsteam Recruits alveoli that have collapsed Slide 27 Washington EMT-B CPAP Curriculum27 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 Slide 28 Washington EMT-B CPAP Curriculum28 Pulse Oximetry Basic concept of Pulse Oximetry monitoring. Objectively determines oxygenation status when applied correctly. Measures the hemoglobin saturation in the bloodstream via red and infrared light, through the skin to the arterial bed. Slide 29 Washington EMT-B CPAP Curriculum29 Pulse Oximetry Possible invalid readings Low blood flow states, (i.e., shock states, hypothermic, hypovolemia) may show an inaccurate low oxygenation percent. Carbon monoxide poisoning may show a false high percent reading. Anemias and oxygen capacity carrying diseases (i.e., sickle cell) may also show a false high reading. Fingernail polish, excessive grease and dirt, nail-tips, or gel nails may cause a false low reading. Slide 30 Review of Respiratory Distress Slide 31 Washington EMT-B CPAP Curriculum31 Respiratory Distress Work of Breathing Respiratory rate greater than 25/minute The presence of retractions and/or use of accessory muscles Appearance = Mental Status Pulse Oximetry < 94% Effects of hypoxia and hypercarbia indistinguishable Circulation/Skin Color Severe cyanosis Pallor and diaphoresis Slide 32 Washington EMT-B CPAP Curriculum32 Focused History and Physical Ascertain the patients chief complaint that may include: Dyspnea Chest pain Cough ProductiveNon-productiveHemoptysis Wheezing Signs of infection Fever, chills Increased sputum production Slide 33 Washington EMT-B CPAP Curriculum33 History Previous experiences with similar/identical symptoms Known pulmonary diagnosis Medication history Current medications Medication allergies Pulmonary medications Cardiac-related drugs History of the present episode Exposure and smoking history Slide 34 Washington EMT-B CPAP Curriculum34 Pulmonary Edema Congestive Heart Failure Defined Fluid which collects in the lung tissue and alveoli Signs/Symptoms/Assessment Anxious, Pale, Clammy, Dyspnea, Tachypnea, Confusion, Edema, Hypertension, Diaphoretic Rales, Ronchi, Tachycardia, JVD, Pink Frothy Sputum, Cyanosis Slide 35 Washington EMT-B CPAP Curriculum35 Pulmonary Edema Congestive Heart Failure Signs/Symptoms/Assessment Fatigue Nocturia Dyspnea on exertion Paroxysmal nocturnal dyspnea Chest Pain Orthopnea Slide 36 Washington EMT-B CPAP Curriculum36 Pulmonary Edema Congestive Heart Failure Treatment Focused history and physical exam Complains of trouble breathing. Airway control w/ adequate ventilation Oxygenation Has a prescribed nitroglycerine available. Consult medical direction. Facilitate administration of nitroglycerine Baseline vital signs. Reassess Slide 37 Washington EMT-B CPAP Curriculum37 Chronic Obstructive Pulmonary Disease (COPD) Defined Lung tissue loses elasticity secondary to destruction of the alveoli (Emphysema) Inflammation of the bronchial tree. Diagnosed by productive cough which lasts at least three months a year for at least two consecutive years (Chronic Bronchitis) Any COPD patient may have both Slide 38 Washington EMT-B CPAP Curriculum38 Chronic Obstructive Pulmonary Disease (COPD) Signs/Symptoms/Assessment Exertional dyspnea Productive cough/wheezing Minor hemoptysis Tachypnea/exertional muscle use Pursed lip exhalation May have coarse crackles Accessory muscle use Hyperexpansion of the thorax (diminished breath sounds) Excessive caloric expenditure Slide 39 Washington EMT-B CPAP Curriculum39 Chronic Obstructive Pulmonary Disease (COPD) Signs/Symptoms/Assessment Tachypnea, cyanosis, agitation, tachycardia, hypertension Confusion, tremor, stupor, apnea Slide 40 Washington EMT-B CPAP Curriculum40 Chronic Obstructive Pulmonary Disease (COPD) Treatment Focused history and physical exam Complains of trouble breathing. Airway control w/ adequate ventilation Oxygenation Has a prescribed inhaler available. Consult medical direction. Facilitate administration of inhaler Repeat as indicated. Baseline vital signs. Reassess Slide 41 Washington EMT-B CPAP Curriculum41 Asthma Defined Condition which causes the bronchi to constrict making it difficult to exhale (air trapping) May be caused by allergic reactions and/or emotional distress The most serious form, status asthmaticus, is a true life-threatening emergency Slide 42 Washington EMT-B CPAP Curriculum42 Asthma Signs/Symptoms/Assessment Dyspnea, chest tightness, wheezing, and cough Obvious SOB, wheezing, accessory muscle use, paradoxical respirations, hyperresonance, prolonged expiration Change in Mental Status: agitation, confusion, lethargy, exhaustion Cardiac Arrhythmias Slide 43 Washington EMT-B CPAP Curriculum43 Asthma Treatment Focused history and physical exam Complains of trouble breathing. Airway control w/ adequate ventilation Oxygenation Has a prescribed inhaler available. Consult medical direction. Facilitate administration of inhaler Repeat as indicated. Baseline vital signs. Reassess Slide 44 Washington EMT-B CPAP Curriculum44 Pneumonia Defined Inflammation of both the bronchioles and alveoli May be viral, bacterial, or fungal. Spread by droplets or contact with infected person Common cause of death in North America Slide 45 Washington EMT-B CPAP Curriculum45 Pneumonia Signs/Symptoms/Assessment Acute onset of chills, fever, dyspnea, pleuritic chest pain, cough, adventitious breath sounds. In geriatric patients, the primary sign may be an altered mental state. Slide 46 Washington EMT-B CPAP Curriculum46 Pneumonia Treatment Focused history and physical exam Complains of trouble breathing. Airway control w/ adequate ventilation Oxygenation Has a prescribed inhaler available. Consult medical direction. Facilitate administration of inhaler Repeat as indicated. Baseline vital signs. Reassess Slide 47 Treatment with CPAP Slide 48 Washington EMT-B CPAP Curriculum48 Essential Components Of A CPAP System 1. CPAP Control Unit Slide 49 Washington EMT-B CPAP Curriculum49 Essential Components Of A CPAP System 2. Breathing Circuit and Positive Pressure Face Mask Slide 50 Washington EMT-B CPAP Curriculum50 Essential Components Of A CPAP System 3. Oxygen Source Slide 51 Washington EMT-B CPAP Curriculum51 Treatment With CPAP Indications Patient in respiratory distress with signs and symptoms consistent with: Congestive Heart Failure (CHF); Pulmonary Edema; asthma; COPD; or pneumonia Other measures to improve oxygenation and decrease the work of breathing have failed (i.e., 100% O2 via NRM) And who is: Awake and able to follow commands; Is over 12 years of age and is able to fit the CPAP mask; Has the ability to maintain an open airway; And Exhibits two or more: RR > 25 BPM SPO2