CPAP and EMS
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Transcript of CPAP and EMS
We Can All Breathe a Little Easier with CPAP
Brian D. King, AS, NREMT-P
Christopher A. Johnson, BS, NREMT-P
What is CPAP?
Continuous
Positive
Airway
Pressure
Why CPAP
• Better for the patient
• Reduction in morbidity and mortality
• Less invasive then intubation
• Less complications than intubation
• Reduction in pre-hospital intubation
• Reduction in length of stays and ICU admissions
• It’s cost effective
What are we using CPAP for?
• The treatment of respiratory distress secondary to Congestive Heart Failure (CHF)
• Other Respiratory Conditions: • Pneumonia • Asthma • COPD
Evidenced Based Medicine
• Berstein, A. et al New England Journal of Medicine; 1991, 325:1825-1830• 65% reduction in ED ETI
• Lin M, Yang TG, Chiang, et al Chest; 1995: 107:1379-86• 75% reduction in ICU ETI
• Hastings, D., et al Journal of Emergency Medical Services; 1998 23(9):58-65• 85% reduction in PEC ETI• 50% reduction in ICU LOS
• Sacchetti, AD Harris, RH Postgraduate Medicine 1998 Feb;103 (2): 145-7, 153-4, 160-2• 90% averted ETI in ED
MORE Studies
• Cincinnati EMS • Mean LOS of 3.5 days for non ETI • Mean LOS of 11 days for ETI
• Galveston EMS• ICU admission decreased 52%• Avg LOS decreased from 14.8 to 8 days
Case Study #1
• 23:00 hours on a cool October evening
• Difficulty breathing (6D1)
• BLS is 6 minutes & ALS is 11 minutes from the scene
• 84 YOF
• CC: “Shortness of Breath”
• Increasing noctournal dyspnea for 3 days
• Tonight started to “choke on phlegm” and developed trouble breathing
Case STUDY #1
• Hx:• CHF, HTN
• Meds:• Lasix, Lisinopril, Coreg, Propoxyphene
• “Found in chair with moderate difficulty breathing on nasal O2 at 5lpm.”
• Initial Vital Sings: • Pulse: 120• Resp: 36• BP: 158/P
• SpO2: 90%
• GCS: 15• Lung Sounds: Bilateral Rales
CASE STUDY #1
• BLS applies NRB @ 15 lpm
• Three minutes latter places patient on CPAP with 10 of PEEP
• ALS arrives on scene and continues CPAP
• Vital Signs 12 minutes post CPAP:• Pulse: 104• Resp: 32• BP: 148/72
• SpO2: 97%
• GCS: 15
• Dx: • Pulmonary Edema due to heart failure
Anatomy & Physiology Review
Respiratory Cycle
• Two Phases • Inspiration • Expiraton
Inspiration
• Active process requiring muscles to have energy and function
• Diaphragm and intercostal muscles contract
• Diaphragm moves downward
• Ribs move upward and outward
• Increased chest size allows air to flow into the lungs (less pressure inside)
Exhalation
• Passive process allowing muscles to relax
• Diaphragm rises
• Ribs moves downward and inward decreasing chest cavity size
• Smaller chest size allows air to flow out of the lungs (less pressure outside)
Right Atrium
Right Ventricle
Left Atrium
Left Ventricle
Receives blood from veins; pumps to right ventricle.
Receives blood from lungs; pumps to left ventricle.
Pumps blood to the lungs.
Pumps blood through the aorta to the body.
Four Chambers of the Heart
ASSESSMENT & PHYSICAL EXAM
INITIAL IMPRESSION
• Cyanosis
• Labored respirations
• Audible sounds
• Tripod position
• Frothy sputum
• Accessory muscle use
• O2 tubing
The ABC’S
VITALS SIGNS
• Interpreting Vital Signs • Respirations
• SpO2
• Pulse• Blood Pressure • Skin
• Physical Exam • Lung Sounds
Respirations
• Adequate Respirations• 12-20• Tidal Volume
• 500ml at rest
• Tachypnea• Hypoxia • Fever• Pain
• Bradypnea • Respiratory failure • Impending respiratory arrest
Pulse OX
• >92%
• <75-80% accuracy greatly diminishes
Pulse
• Normal • 60-100
• Slow• < 60
• Rapid• > 100
• Irregular
• Regularly, Irregular• Atrial Fibrillation
Blood Pressure
• Systolic• 100-140 mmHg
• Diastolic• 60-90 mmHg
• High vs. Low
Skin
• Color• Normal
• Pale
• Others
• Temperature• Hot
• Warm
• Cool
• Cold
• Condition • Dry
• Moist
• Wet
• Edema
PITTING EDEMA
Lung Sounds
• Normal
• Rales / Crackels
• Rhonchi
• Wheezing
• Diminished
History
Clinical History
• Dyspnea at rest
• Dyspnea upon exertion
• Orthopnea
• Paroxysmal Nocturnal Dyspnea
• Cough
• Edema
• Chest Pain
• Abdominal Distention
• Diaphoresis
• Anxiety
• Smothering sensation
Past Medical History
• CHF
• Atrial Fibrillation• Loss of atrial kick.
• MI
• Diabeties
• Renal Failure
• Dialysis
• Alcohol use
• Hypertension
• High Cholesterol
Medications
• Diruetics• Lasix • Bumex
• ACE Inhibitors• Captopril • Enalapril • Lisinopril
• Cardiac Glycosides• Digoxin
• Beta Blockers • The “olol” drugs • Beware of masked tachycardia
Heart Failure
• The inability of the heart to maintain an output adequate to sustain the metabolic demands of the body
Pulmonary Edema & Acute Pulmonary EDEMA• An abnormal accumulation of fluid in the
lungs
Conditions that mimic CHF
COPD
• Triad of distinct diseases that often coexist: • Chronic Bronchitis • Emphysema• Asthma
Chronic Bronchitis
• Inflamatory changes and excessive mucous production in the bronchial tree
• Commonly caused by prolonged exposure to irritants
The “BLUE BLOATER”
Emphysema
• Characterized by: • Permanent abnormal
enlargement of the air spaces beyond the terminal bronchioles
• Destruction of the alveoli • Failure of the supporting
structures to maintain alveolar integrity
• Results in:• Reduced surface area • Reduced elasticity, leading to air
trapping • Residual volume increases while
vital capacity remains normal
The “PINK PUFFER”
Asthma
• Common chronic disorder of the airways that is complex and characterized by variable and recurring symptoms
• Asthma Triad: • Increased mucous production• Increased bronchial edema• Bronchospasm
Asthma
Pneumonia
• Infection in the lung, specifically the alveoli
CPAP
What EXACTLY IS CPAP?
Where does CPAP FALL
PEEP
• Positive End Expiratory Pressure• the amount of pressure above atmospheric pressure
present in the airway at the end of the respiratory cycle
• Goal of PEEP: • Improve oxygenation
• Amount of PEEP: • 5-10 cm H2O
• Too 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.
What we are doing
• In 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
What we want to do!
• Put more oxygen into the blood • Improving gas exchange
• Maintain a positive pressure in the lungs• Move some of the fluid out of the lung• Stops fluid from moving into the lungs
• Open the alveoli to preventing collapse
• Increasing the surface area in the alveoli will improve the gas exchange
• Increases intrathoracic pressure• Improves cardiac output to a degree• Too Much PEEP decreases cardiac output
What will we see?
• In a perfect world: • Improved gas exchange• Decreased anxiety • Improved vital signs
• Decreased blood pressure • Decreased pulse rate
• Increased SpO2
• Improved respiratory effort • Decreased respiratory rate
• Decreased need for intubation
• 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 CPAP• Some patient’s will require intubation
BUT WHAT HAPPENES TO THE FLUID?
• The fluid is not being removed from the body by CPAP
• CPAP does not fix the entire problem
Things we may see
• Gastric distention
• Corneal drying
• Hypotension
• Pneumothorax
• Anxiety
CPAP ConTraindications
• Unconscious
• Inability to protect airway
• Respiratory Arrest
• Need for BVM or Intubation
• Vomiting
• Facial trauma
• Increased ICP (>20mmHg) – Unknown for us
Not a candidate for CPAP
Case Study #2
• 0028 hours
• “Interfacillity-Difficulty Breathing” 33C2
• BLS is 4 minutes & ALS is 10 minutes from the scene
• 90 YOF
• CC: “shortness of breath” per the staff
• Per staff “sudden onset of shortness of breath
• Staff relates that the patient began to “choke” on something.
Case Study #2
• Hx:• CHF, HTN, CVA, Atrial Fibrillation
• Meds:
• Furosemide, Norvasc, Nitro, Coumadin, Digoxin
• “Found laying in bed with a simple mask and gurgling respirations”
• Initial Vital Signs:• Pulse: 130• Resp: 40 and shallow• BP: 200/100• GCS: 9• Lung Sounds: Rale bilaterally
• BLS suctions the patient’s airway
• When sitting the patient up, patient has snoring respirations.
Case Study #2
• REMEMBER: Patient’s must have a self-maintained airway for CPAP applications.
• Airway management• Nasal • Oral • Positioning• Intubation
• Manual positive pressure ventilations may be preferred with a BVM
CPAP DEVICES
Downs generator
Downs generator
• Requires a high pressure oxygen source
• Requires a complete CPAP system
• Closed system
• Easily adjustable PEEP
Boussignac
Boussignac
• Currently used for the NCC BLS Pilot Study.• Low investment • No additional equipment• Completely Disposable • As simple as applying a non-rebreather• Small Size
• Open system • Eliminates rebreathing • Able to suction using a French catheter without
losing pressure• Allows use of a nebulizer
CPAP Os
CPAP OS
• High Cost for the system
• Requires a high pressure oxygen source
• Requires a complete CPAP system
• Closed system
• Easily adjustable PEEP with large guage
CareVENT
Carevent
• High cost
• Offers the best of both worlds • Transport ventilator for intubated patients• CPAP
• Requires a high pressure oxygen source though consumes less oxygen in comparison to other models
• Requires a complete CPAP system
• Closed system
QUESTIONS? Contact us:
Brian: [email protected]: [email protected]