Rama

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Rama Beausoleil CPAP CME 2009
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Agenda

• Welcome housekeeping
• CPAP didactic review
• Break
• Skills
• CPAP MACS
• Scenarios
• KAT
• Course evaluation

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Prehospital CPAP
Reviewed by MAC May 2008
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Acknowledgements
REVIEWERS/CONTRIBUTORS Dr. Sheldon Cheskes,
MD SOCPC Ted Reesor, RRT Tim Dodd, AEMCA,
ACP Chair, OBHG Education Subcommittee Hamilton
Base Hospital Maud Huiskamp, AEMCA,
ACP SOCPC
AUTHOR Cathie Hedges, ACP Essex Kent
(Windsor) Base Hospital
2008 Ontario Base Hospital Group
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Objectives

• Anatomy overview
• O2 saturation monitoring
• Positive End Expiratory Pressure (PEEP)
• Continuous Positive Airway Pressure (CPAP)

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Respiratory System

• UPPER RESPIRATORY TRACT
• Oro/nasopharynx
• Larynx
• Trachea to the carina

What is the major function of these structures?
Warms, Filters Humidifies
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Respiratory System

• LOWER
• RESPIRATORY
• TRACT
• Trachea
• Bronchi
• Bronchioles
• Alveoli

Whats the main occurrence here?
Gas exchange!
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Lungs
Where does gas exchange occur?
Where the Circulatory and Respiratory Systems
join together
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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

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The Act of Breathing ..

• INSPIRATION
• Diaphragm
• Intercostal muscles
• Creates a negative pressure in the lungs
  (alveoli) compared to the atmosphere
• Atmospheric air rushes in to fill the void
• Gas exchange occurs by diffusion.

contracts (drops)
contract (ribs go up out)
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Mechanics of Ventilation

• Exhalation
• ? Thoracic Cage
• Passive Process

• Inspiration
• ? Thoracic Cage
• ? 3 mmHg Alveolar Pressure

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Oxygen Saturation

• Pulse oximetry is a tool used to monitor the
  effectiveness of the patients respiratory status
  so treatment can ensure that adequate and
  effective oxygenation is maintained.

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Why use O2 Sat monitors?

• Does the physical assessment alone provide an
  adequate picture for good oxygen saturation?

Hypoxemia may not be evident until oxygen
saturation levels are quite low
For example cyanosis to lips, nail beds, ear lobes
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Pulse Oximetry Review

• Pulse oximeters consist of a sensor containing a
  light source and a photodetector.
• Technology based on a colour spectograph the
  photodetector determines the light absorbed while
  passing through the capillaries then displays
  the calculated saturation levels.
• .How can it be fooled?

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Factors affecting Oximetry

• Strong ambient light sources
• Poor circulation
• Cardiac arrest
• Hypothermia
• Shock
• Anemia
• CO poisoning
• Nail polish

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Plethograph

• Also know as the O2 sat waveform
• If the waveform is the same with each pulse, then
  the numeric value will be accurate.

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Take Home Points

• Oxygen saturation may be utilized to monitor a
  patients condition
• Do not restrict oxygen delivery based on
  numerical values.
• Remember to treat the patient not the monitor.
  If the patient appears ill and you feel oxygen
  will benefit the patient, give oxygen! -
• It grows on trees!!

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What is PEEP? Positive End Expiratory Pressure

• Mechanically maintaining airway pressure above
  atmospheric pressure at the end of exhalation.
• Decreases the shunting of blood through the lungs
  and improves gas exchange.
• PEEP is done in ARDS (acute respiratory distress
  syndrome) to allow reduction in the level of
  oxygen being given.
• The equivalent in a spontaneously breathing
  patient is

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CPAP

• ontinuous
• ositive
• irway
• ressure

C P A P
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CPAP Learning Objectives

• History of CPAP
• Goal of CPAP in the field
• CPAP and its physiological effects
• Medical applications of CPAP
• CPAP Medical Directive
• Contraindications CPAP
• Delivery Systems

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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)
• 1992 CPAP to spontaneously breathing patients
  (Keilty et al)

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Some Facts

• The Aging Patient Population is increasing
  dramatically as Baby Boomers are reaching
  retirement age
• Multiple factors (diet, lack of exercise, etc)
  are causing a surge in cardiac and respiratory
  problems

• The Canadian Heart and Stroke Foundation reports
• Heart failure is on the increase as a result of
  successes in treating heart attacks and other
  cardiac conditions
• It is estimated that there are 400,000 Canadians
  living with congestive heart failure (CHF).
• Up to 40 to 50 of people with congestive heart
  failure die within five years of diagnosis.

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Some More Facts

• CPAP provides an adjunct between oxygen by NRB
  and Endotracheal Intubation
• Reduces days in hospital without a reduction in
  quality of care
• Reduces trauma infection risks associated with
  intubation
• Of those with ventilator acquired pneumonia 50
  will die CPAP may help avoid the ventilator
  greatly reducing this risk!!
• (Implementation of Guidelines on
  hospital-acquired pneumonia. Torres, Antoni. 128,
  Barcelona, Spain  Chest, 2005. 1900-1802.)

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Goal of Prehospital CPAP

• Provide an effective way to
• treat CHF/COPD by
• Increasing Functional Residual Capacity (FRC) -
  volume of gas remaining in lungs at
  end-expiration
• Distending alveoli preventing collapse on
  expiration and providing a greater surface area
  improving gas exchange

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How Does CPAP Work?

• A tight fitting mask controlled by a regulator
  designed to provide a high flow of variable or
  fixed oxygen concentration.
• Most important feature is a flow restriction
  device at the exhalation port of the mask, which
  works the same way as Positive End Expiratory
  Pressure (PEEP).
• Places the patients airways under a constant
  level of pressure throughout the respiratory
  cycle, causing fluid and other obstructions to be
  "pushed" back where they belong.

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How Does CPAP Work?

• Splints the airways open, increasing potential
  for gas exchange
• Increases surface area of the alveoli,
  increasing potential for gas exchange.
• Decreases the work of the heart by increasing
  oxygenation.

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Before CPAP treatment
Decreased area for gas exchange
After treatment with CPAP ? venous return and
filling pressures ? compliance ? effective
ventilation ? work of breathing
Increased surface area for gas exchange
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What Is good PEEP/CPAP?

• Fully inflated alveoli
• Even surface area

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What Is Bad PEEP/CPAP?

• Unevenly shaped alveoli
• Collapsing
• Resulting in decrease of surface area

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Good versus Bad
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CPAP and Airway Pressure
The application of positive airway pressure
throughout the respiratory cycle to spontaneously
breathing patients.
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CPAP Reopens Collapsed Airway

• Acts a pneumatic stent i.e.
• Soft palate collapse in obstructive sleep apnea
  (nocturnal CPAP for home use)
• Bronchial collapse (COPD) causing air trapping in
  alveoli
• Alveolar collapse from surfactant washout with
  pulmonary edema
• Each of the above applications increases the
• amount of air left in the lungs after exhalation
  (FRC) by opening blocked passages.

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CPAP and Partial Pressure

• The pressure of a gas mixture is equal to the
  sum
• of the partial pressures of its constituents.
• This allows oxygen into the blood during
  inspiration
• and Carbon Dioxide out during expiration.
• Example Air at sea level has a pressure of
• 760mm Hg.
• Air is 21 oxygen and 79 nitrogen.
• Partial pressure of oxygen at sea level is
• 760 X 21 159mm Hg

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CPAP and Partial Pressure

• Remembering air is 21 oxygen and 79
  nitrogen, and at sea level has a pressure of
  760mm Hg, what is the partial pressure of
  nitrogen at sea level?
• 760 X 79 600 mmHg

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Pressure Gradient
So why does oxygen pass into the blood?

• Deoxygenated blood has a lower partial pressure
  of oxygen than alveolar air so oxygen transfers
  from the air into the blood.

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7.5cm H20 CPAP
CPAP alters the pressure gradient!

• 1cm H2O is equal to 0.735mm Hg.
• 7.5cm H2O CPAP increases the partial pressure
• of the alveolar air by approximately 1.
• This increase in partial pressure forces more
• oxygen into the blood.
• Even this comparatively small change is enough
• to make a clinical difference.

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Advantages of CPAP

• Flexibility in initiating, interrupting, and
  discontinuing mechanical ventilation
• Decreases the need for ICU admission
• Improves patient comfort
• Psychological advantage to the patient
• Preserves speech and swallowing, allowing patient
  to communicate with family and staff

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CPAP versus ETT versus PPV

• CPAP
• Non-invasive
• Easily discontinued
• Easily adjusted
• Does not require sedation
• Comfortable

• Intubation
• Invasive
• Potential for infection
• Requires highly trained personnel
• Can require sedation
• Traumatic for the patient

• PPV
• Non-invasive
• Easily discontinued
• Difficult to monitor
• Does not require sedation
• Comfortable

• A clinical decision should be made based on the
  severity and condition of the patient and
  whether intubation is necessary
• CPAP requires the patient to be awake,
  spontaneously breathing and able to maintain an
  open airway

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Acute Pulmonary Edema versus CHF

• There could be crackles on auscultation for both,
  why do I need to know the difference?

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(No Transcript)
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Assessment Treatment

• A Assess and control airway.
• Patient positioning
• B Assess breathing.
• Give O2 PPV
• SpO2
• C Assess circulation
• Cardiac monitor
• 12 Lead ECG PRN
• Pulse (location)
• BP
• JVD
• Gain IV access
• NTG as per medical directive
• CPAP as per medical directive

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Ventolin and CHF?!

• Drug classification?
• How does it work on the CV system?
• Is it a good thing to give Ventolin if the
  patient has wheezing when suffering from CHF or
  APE?

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CPAP And Pulmonary Edema

• Severe pulmonary edema is a frequent cause of
  respiratory failure
• CPAP increases functional residual capacity
• CPAP increases transpulmonary pressure
• CPAP improves lung compliance
• CPAP improves arterial blood oxygenation
• CPAP redistributes extravascular lung water
• (Rasanen 1985)

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Redistribution Of Extravascular Lung Water With
CPAP
CPAP And Pulmonary Edema
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Define COPD

• Chronic Obstructive Pulmonary Disease
• Any disorder that persistently obstructs
  bronchial airflow.
• COPD mainly involves two related diseases --
  chronic bronchitis and emphysema.
• The obstruction is generally permanent and
  progresses over time.
• ASTHMA IS NOT COPD

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CPAP And COPD

• CPAP overcomes inspiratory work imposed by
  auto-peep
• CPAP prevents airway collapse during exhalation
• CPAP improves arterial blood gas values
• CPAP may avoid intubation and mechanical
  ventilation
• (Miro 1993)

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CPAP Common Complications

• Pressure sores
• Gastric distension
• Pulmonary barotrauma
• Reduced cardiac output
• Hypoventilation
• Fluid retention

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Medical Directive

• Indications
• Patient is awake and able to follow commands in
  moderate to severe respiratory distress as
  evidenced by two of three of the following
• Respiratory rate gt24 breaths per minute
• SpO2 of lt 90 at any time
• Accessory muscle use

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Medical Directive

• Indications (continued)
• AND with signs and symptoms consistent with
• exacerbation of chronic obstructive pulmonary
  disease (COPD),
• acute pulmonary edema, OR
• acute congestive heart failure (CHF)

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Medical Directive Absolute Contraindications

• Pt unable to cooperate
• Suspected pneumothorax
• Major trauma/burns (face, neck, chest/abdomen)
• Unable to sit upright
• Facial anomalies
• Tracheostomy

• Intubated patient
• Resp rate lt 8
• Systolic BP lt 90
• Age lt 12 or lt 40 kg
• Decreased mentation
• Potential airway compromise i.e. Vomiting, FBO,
  GI bleed
• Cardiac arrest

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Documentation

• ACR special equipment code 63

Document on the ACR Code 339 each time you
adjust the CPAP settings Reassessments are
documented every 5 minutes Code 010 Vital Signs
Code 336 Respiratory evaluation
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When do I bring the CPAP device to a call?

• All calls with a complaint of SOB
• All calls with a complaint of CP

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How do I titrate CPAP to effect?

• Titration what is that?
• Is the process of gradually adjusting the dose
  until the desired effect is achieved.
• Titration criteria
• Clinically no improvement in respiratory
  distress
• Respiratory rate
• Work of breathing
• Use of accessory muscles
• Lack of improvement in SpO2

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Titration to effect

• Increase CPAP by 2.5 cm H2O
  Q 5 minutes when
• No clinical improvement
• To a maximum of 15 cm H2O

• Increase FIO2 to 100 when
• SpO2 remains below 90 during treatment OR
• If no clinical improvement at 10 cm H2O CPAP

• Clinical improvement
• No changes in CPAP
• No changes in FIO2

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Discontinue use

• When the patient cannot tolerate the mask after
  coaching
• Patient begins to vomit
• Patient experiences a respiratory rate lt8
• PPV with BVM or endotracheal intubation should be
  considered if the patient is removed from CPAP
  therapy
• Treat the circuit as medical waste

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MACS CPAP device
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Program Objectives

• Describe the main operating features of MACS
• Identify the controls and connections
• Describe the patient circuit
• Set-up MACS for patient operation
• Clean and maintain the MACS

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Features and Controls Rear Panel

• Driving Gas Input
• Connection for 50 psi oxygen source gas
• Always use a high flow gas source (pressure
  take-off) that can provide 55 15 psi pressure
  at a minimum of 40 L/min

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Features and Controls Rear Panel

• Air Entrainment
• Ambient air is entrained for internal gas mixing
• External housing contains air filter
• Air filter replacement is part of the
  preventative maintenance

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Features and Controls Front Panel

• CPAP Control
• Adjusts the CPAP from 0 to 20 cm H2O
• Automatic sensitivity
• Flow adjusts automatically to meet patient demand
  up to 140 L/min
• Oxygen concentration is maintained at set
  Oxygen control

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Features and Controls Front Panel

• Oxygen Control
• Delivered oxygen choice
• 65
• 100
• Sets the spontaneous breath oxygen concentration

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Features and Controls Front Panel

• Pressure Gauge
• Shows pressure in patient circuit at the output
  of MACS
• Gives an indication of patient effort

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Features and Controls Front Panel

• Circuit Connection 1
• Connection for the large bore hose of the
  patient circuit

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Features and Controls Front Panel

• Circuit Connection 2
• Patient circuit small hose connection
• Connects to the expiratory valve on the patient
  circuit

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Patient Circuit

• Patient circuit is a disposable, single limb
  system
• Both hoses attach to the front of MACS
• Patient end connects for clinical intervention
• Resuscitator face mask (noninvasive)

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Patient circuit

• Circuits will need to be assembled with 2 filters
  for personnel and patient safety

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Patient Application

• Initial Set-up
• Attach a high pressure oxygen hose to the rear of
  MACS
• Attach this hose to the oxygen source
• Attach the circuit to the front of the MACS

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Patient Application

• Set Oxygen Control
• Set Oxygen control to 65
• All breaths receive set oxygen level 10
• Oxygen tank time doubles with 65
• Caution - with rapid, large tidal volumes on 100
  oxygen, the actual delivered percentage might be
  slightly less than 100

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Approximate operating time using a full D tank
Based on 10cm of water CPAP
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Apply mask to the patient

• Carefully explain the procedure to the patient
• Size the mask (one size fits most)
• Harness may be applied to one side prior to
  application
• Hold the mask in place while coaching the patient
• Tell the patient that you are going to secure the
  mask
• Secure and adjust the head straps once the
  patient is accepting the mask
• One strap above the ear
• One strap below the ear

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Mask application
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What about.

• Facial hair?
• You may need to adjust the mask a little more
  tightly
• Dentures?
• Put teeth in for a better mask fit
• Air leak?
• Minor leak, leave as is. You do NOT need a tight
  seal, the mask needs to fit properly and
  comfortably. MACS is not a closed system and does
  not require a tight seal.
• Major leak, you will see frequent blinking of the
  patient. Adjust the BOTTOM straps to improve the
  fit
• Mask size?
• The mask is designed to fit on the face or
  underneath the chin to accommodate patients of
  many sizes.

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Patient Application

• Start CPAP
• Turn on oxygen source
• Attach patient breathing circuit to the patient
• Adjust the CPAP control to the level desired up
  to a max 15 cm H2O
• If the patient is not attached to the circuit, or
  there is a large leak, a high flow of gas will
  occur
• The machine will leak compensate

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Patient Application

• Monitor patient
• Reassess Q 5 minutes
• Reassess response to treatment
• vital signs
• O2 Sat
• Document your findings

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Patient monitoring LP12
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NTG administration as per medical directive

• The mask may be removed for a short time to
  administer NTG as indicated.
• Have the patient hold the mask, remove the
  straps, administer NTG, hold the mask, and apply
  the straps.
• As tolerated by the patient.

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MDI Ventolin administrationas per medical
directive

• An MDI adapter may be placed between the 90º
  elbow and the mask.
• Coordinate the administration of each dose with
  the patients inhalation.

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CPAP switching O2 sources

• When transferring oxygen sources from the
  portable D tank to the ambulance then to the
  hospital source, make the transition as quickly
  as possible so as not to lose too much positive
  pressure.

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Patient Safety Features

• Internal Safety Pressure Release limits circuit
  pressure to 40 cm H2O
• Anti-Suffocation System in the event of device
  malfunction, an internal valve will allow ambient
  air to enter the patient circuit

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Cleaning and Maintenance

• Clean MACS between patients using a soft cloth
  and a mild detergent / disinfectant
• Do not immerse MACS in water
• Patient circuit is disposable, single use
  application and should not be cleaned,
  disinfected or reused
• MACS should receive preventative maintenance
  every 2 years