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Prehospital CPAP

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'Oxygen Therapy In It's Most Efficient Form' Continuous Positive Airway Pressure. What Is CPAP ... Time = (f X PSI) / LPM. Tanks at 1000 PSI 'D' (f = 0.16) = 1 ... – PowerPoint PPT presentation

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Title: Prehospital CPAP


1
Prehospital CPAP Provider Training
2
Acknowledgements
  • Dave Pavlakovich, RRT,
  • University of Texas Medical Branch, Galveston, TX
  • Dave Henning, NREMT-P, CCP
  • Gold Cross Ambulance Service, Manasha, WI

3
Topics For Today
  • -Overview of Respiratory Mechanics
  • -Most Common Respiratory Dysfunctions
  • -What is CPAP?
  • -How Can We Use CPAP?
  • -Exclusions
  • -Protocols
  • -Assessment
  • -Data Collection
  • -Practical

4
Respiratory Mechanics
  • Components of the Airway

5
Respiratory Mechanics
  • Oxygenation and Ventilation

6
Respiratory Mechanics
  • Functional Residual Capacity

7
Respiratory Mechanics
  • Peak Inspiratory Flow

8
Common Dysfunctions
Obstructive vs. Restrictive Disorders
9
Common Dysfunctions
COPD
Obstructive Issues Gas Exchange Issues Muscle
Tiring
10
Common Dysfunctions
Acute Pulmonary Edema
Pressure Changes and fluid shift VQ
Mismatch Distress and sympathetic discharge
11
Diagnosis of APE
  • Symptoms
  • Acute onset shortness of breath
  • Physical exam findings
  • Rales, legs
  • Pedal edema
  • JVD
  • Chest XRay findings for CHF
  • Echocardiograms Low ejection fraction/poor
    contractility (hypocontractility)

12
How do you know an EMS patient has Heart Failure?
  • Ask 3 Questions
  • 1. History of Congestive Heart Failure?
  • 2. RALES on Lung Examination?
  • 3. EDEMA to Legs?

Burton , J. CHF in EMS 2005
13
What Is CPAP
Continuous Positive Airway Pressure
  • Breathing Against A Threshold of Resistance
  • Pneumatic Splinting of Airways
  • Oxygen Therapy In Its Most Efficient Form

14
What Is CPAP
  • In Our Program.
  • -Mask
  • -Tubing
  • -Gas Source
  • -PEEP Regulation
  • -Generator

15
What Is CPAP
  • In Our Program.
  • -Air is mixed with oxygen via a venturi system or
    with a Downs Flow Generator

16
What Is CPAP
  • -Resistance is regulated with a positive end
    expiratory pressure (PEEP) valve.

17
What Is CPAP
18
Effects of CPAP
  • -Increased Functional Residual Capacity
  • -Reduced Work Of Breathing
  • -Increased Oxygen Diffusion Across Alveolar
    Membrane
  • -Increased Alveolar Surface Area

19
Effects of CPAP
  • Acute Pulmonary Edema
  • Changes Pressure Gradients
  • Reduces Work of Breathing Sympathetic Discharge
  • Can Decrease Preload

20
CPAP therapy can improve A.P.E. patients in 90
seconds.
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)
21
How We Can Use CPAP
  • Acute Pulmonary Edema
  • CPAP is to APE like D50 is to insulin shock
  • Russell K. Miller Jr, MD, FACEP

22
But Maine has many inexperienced providers
What about misdiagnosis?
23
2003 Helsinki EMS Looked at patients in Acute
Severe Pulmonary Edema (ASPE) 121 patients
included Used low concentration FiO2, IV Nitrates
and No lasix 4 patients intubated in field
Mean O2 Saturation From 77-90 Hospital
mortality 17.8 (non CPAP)-8 (CPAP) Only 83
patients were confirmed to have chf (Kallio, T.
et al. Prehospital Emergency Care. 2003. 7(2) )
24
Keep in mind Helsinki -34 (non chf) of 121 still
got better There is sparse research anecdotal
evidence for use in other etiologies
25
Limitations of CPAP
  • CPAP IS NOT MECHANICAL VENTILATION!

26
Limitations of CPAP
  • Other Limitations
  • -Increased Intrathoracic Pressure Can Produce
    Hypotension
  • -Psychological Effects
  • -Pneumothorax
  • -Corneal Drying

27
Limitations of CPAP
  • Oxygen Demand
  • Time (f X PSI) / LPM

Tanks at 1000 PSI D (f 0.16) 1-2
Minutes E (f 0.28) 2-4 Minutes M (f
1.59) 10-20 Minutes H (f 3.18) 19-38
Minutes
28
CPAP Indication
  • -APE
  • -Acute respiratory insufficiency

29
CPAP Indication
Acute respiratory insufficiency will be defined
as moderate/severe respiratory distress of 5 word
or less dyspnea concurrent with signs and
symptoms of hypoxia (cyanosis, pulse oximetry
readings of less than 90, etc.), and/or
accessory muscle use.
30
CPAP Exclusions
  • -Patient lt 18
  • -Unstable Airway
  • -Traumatic Etiology of Respiratory. Distress
  • -Severe Altered Mental Status
  • -Facial Trauma or Impossible Face Seal

31
CPAP Protocol
  • Intermediate and Above-Standing Order

32
CPAP Protocol
  • APE
  • MEMS Protocols Plus
  • -Medical Control
  • -CPAP Option
  • Reassess, Reassess, Reassess!

33
CPAP Protocol
  • Psychological Therapy
  • Address the emotional component
  • Dont give up too early but know when to say
    when.

34
Reassess, Reassess, Reassess!
35
MEMS Approved CPAP Systems
  • Whisper Flow, Oxypeep,

36
MEMS Approved CPAP Systems
  • Port-O-Vent, Boussignac

37
CPAP SYSTEMS
  • Oxypeep

38
CPAP SYSTEMS
  • Boussignac

39
CPAP SYSTEMS
  • Boussignac

40
CPAP Documentation
Necessary Elements  Initial Assessment System
Utilized Medical Control Requests 5 Minute
Assessment Arrival Condition
41
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
42
Practical Session
43
QUESTIONS?
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