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7/28/2019 CPAP for Medical Directors
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Pre-Hospital CPAP
What the EMS MedicalDirector should know
Keith Wesley, MDWisconsin State EMS Medical Director
mailto:[email protected]:[email protected]7/28/2019 CPAP for Medical Directors
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Objectives
Review the goal & physiology of CPAP
Discuss the indications and
contraindications for CPAP use
Review the literature supporting CPAP use
Explore the role of CPAP use by pre-
hospital providersDiscuss the methods for implementing
pre-hospital CPAP
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The Goal of CPAP?
Reduce the need for pre-
hospital intubation!
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CPAP vs. Intubation
CPAP
Non-invasive
Easily discontinued
Easily adjustedUse by EMT-B
Minimal complications
Does not require sedation
Comfortable
Intubation
Invasive
Intubated stays intubated
Requires highly trainedpersonnel
Significant complications
Can require sedation or
RSIPotential for infection
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The Problem
Congestive Heart Failure Incidence 10 per 1000 patient (over age 65) transports
25% of Medicare Admissions
Average LOS is 6.7 days 6.5 million hospital days
Those who get intubated have significantly longer LOS
33% get intubated without non-invasive pressure
support Intubated patients have 4 times the mortality of non-intubated patients
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The Problem
CHF/Pulmonary Edema
Interstitial fluid interferes with gas exchange
(ventilation and oxygenation)
Increased myocardial workload resulting in
higher oxygen demands (many of these
patients are suffering ischemic heart disease)
Traditional therapies designed to reduce pre-load and after-load as well as remove
interstitial fluid
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The Problem
COPD/Asthma
Increased work of breathing
Hypercarbic (ventilation issue)
Traditional therapies involve brochodilators
which require adequate ventilation
Higher mortality rate if intubated
Difficult to wean once intubated
Extremely difficult patient to intubate in the
pre-hospital arena usually requires RSI
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Physiology of CPAP
Airway pressure maintained at set level
throughout inspiration and expiration
Maintains patency of small airways and
alveoli
Improves gas exchange
Improves delivery of bronchodilatorsMoves extracellular fluid into vasculature
Reduces work of breathing
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Supporting Literature
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
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Supporting Literature
Reviews in Cardiovascular Medicine, vol. 3 supl. 4 2002,Role of Noninvasive Ventilation in the Management of
Acutely Decompensated Heart Failure
Though BLPAP has theoretical advantages over CPAP,there are questions regarding its safety in a setting ofCHF. The Key to success in using NIV to treat severeCHF is proper patient selection, close patient monitoring,proper application of the technology, and objective
therapeutic goals. When used appropriately, NIV can bea useful adjunct in the treatment of a subset of patientswith acute CHF at risk for endotracheal intubation.
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Supporting Literature
Brochard (French abstract) Noninvasive
ventilation for acute exacerbations of
COPD
can reduce the need for intubation, LOS
in hospital, and mortality rate
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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
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Pre-hospital CPAP
PEC 2000 NAEMSP Abstract, Pre-hospital use of CPAPfor presumed pulmonary edema: a preliminary caseseries, Kosowsky, et. al.
19 patients
Mean duration of therapy 15.5 minutesOxygen sat. rose from 83.3% to 95.4%
None were intubated in the field
2 intubated in the ED
5 subsequently intubated in hospitalPre-hospital CPAP is feasible and may avert the needfor intubation
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UTMB Experience
Dr. Jeffery Miller UT Galveston
IRB approval through UTMB
6 hours didactic instruction
Recognize CHF trial limited to CHF
Differentiate CHF, COPD, Asthma &Bronchitis
2 hours clinical trainingInstruction on assessment most importantreason for success
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UTMB Experience
Data Summary Sept. 1996 May 1997 Total intubations 22
Hospital stay 14.8 days
ICU admission 100%
Data Summary Sept. 1997 May 1998 CPAP 50
Total intubations 8 (15%)
CPAP failures 4 (8%) Hospital stay 8 days
ICU admission 48%
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Wisconsin EMTBasic Experience
Question: Can EMT-Basics apply CPAP
as safely as Paramedics?
50 EMT-Basic services
2 hour didactic, 2 hour lab, written and
practical test
Required data collectionCompared to same data collected by ALS
services during same period
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Wisconsin EMTBasic Experience
Required data collection
Criteria used to apply CPAP
Absence of contraindications
Q 5 min. vital signs including oxygen sats.
Subjective dyspnea score
Because EMTBasics dont diagnose a
unique Respiratory Distress protocol
used to capture patients
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Adult Respiratory Distress Protocol(Age greater than 12)
Routine Medical Assessment
Oxygen
2 LPM via Nasal Cannula
Titrate to maintain Pulse ox of >92%
Is Patient a candidate for Mask CPAP?
-Respiratory Rate > 25 / min
-Retractions or accessory muscle use-Pulse ox < 94% at any time
See Mask CPAP Protocol
No
Yes
No
No
Is the Patient wheezing and/or does
the Patient have a history of Asthma/COPD?
Does the Patient have rales and/or does the
Patient have a history of congestive heart
failure (CHF)?
YesAdminister Albuterol /
Atrovent by Nebulizer
If Basic IV Tech:
Administer 1 spray
sublingual NTG every
5 minutes as long as
systolic BP is greater than
100mmHg
Yes
Contact Medical Control
Consider ALS Intercept and Transport
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Asses Patient, record vital signs
and pulse ox before applying oxygen
Does the Patient meet two or more
Inclusion Criteria?No
Yes
Does the Patient meet any
Exclusion Criteria?
Continue standard BLS
Respiratory Distress Protocol
Administer CPAP
5 cm H2O of pressure AND
Reassess patient, vital signs, and
respiratory distress scale every 5 min.
Notify Medical Control
Consider ALS Intercept
and continue BLS
Respiratory Distress Protocol
Patient condition is stable
or improving
Continue CPAP
Reassess patient every
5 minutes
Patient condition is deteriorating
Decreasing LOC
Decreasing Pulse Ox
Notify Medical Control
Remove CPAP
Apply BVM Ventilation
Mask CPAP for EMT-Basic
CPAP Inclusion Criteria
(2 or more of the following)
-Retractions or Accessory muscle use-Respiratory Rate > 25 / minutes
-Pulse Ox < 94% at any time
CPAP Exclusion Criteria
-Unable to follow commands
-Apnea
-Vomiting or active GI bleed
-Major trauma / pneumothorax
Conditions Indicated for CPAP
Congestive Heart Failure
COPD / Asthma
Pneumonia
Yes
No
Complete CPAP Data Form and
submit to service Medical Director
for each patient placed on CPAP
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Wisconsin EMT-Basic Experience
Results (preliminary study completed11/05)
500 applications of CPAP (114 services)
99% met criteria for CPAP on review of medicaldirector
No field intubations by those services with ALSintercepts
No significant complications
All oxygen sats. improved, dyspnea reduced byaverage of 50%
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Wisconsin EMT Basic Experience
State approved CPAP for EMT-Basic
scope of practice 2/06
Questions yet to be answered
What conditions did the patients have?
Was it applied too liberally?
Key Point
Services without ALS intercept did just as well
as those with it
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Eau Claire Fire Experience
Paramedic service
July 2003 June 2004
Measured end-tidal CO2, oxygen sats.,and subjective dyspnea score
COPD/Asthma Continuous nebs
CHF Nitro infusion or repeated sprays
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Eau Claire Fire Experience
50 applications
No field intubations
Initial CO2 levels average 62All patients CO2 levels increased during
first 5 minutes
CO2 levels increasing more than 10positively predicted CPAP failure
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Indications for CPAP
CHF
Pulmonary Edema
Near Drowning
Inhalation Exposure
COPD
AsthmaPneumonia
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Items to Consider
How good is current care for respiratory
distress?
Aggressive nitrates for CHF?
Aggressive use of bronchodilators?
Pre-hospital and hospital intubation rate?
Requires active medical oversight
Airway management is a sentinel event
ALS or BLS or BOTH?
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Items to Consider
Equipment
Must be easy to use and portable
Adjustable to patients need
Easily started and discontinued
Provide quantifiable and reliable airway
pressures
Conservative oxygen utilization
Not interfere with administration traditional
therapies for underlying condition
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Items to Consider
Oxygen concentration
Fixed versus Variable rates
Fixed rates are either 35% or 100% in current
models but actual concentration will be lessdepending on leaks and minute ventilation
Variable rate increases chance of inadequate
oxygen supply
Pressure levelMost studies show 5cm H20 sufficient
Complication rate goes up with pressure
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Summary
CPAP is a non-invasive procedure that is
easily applied and can be easily
discontinued without untoward patient
discomfort
CPAP is an established therapeutic
modality
Data supports its use in CHF, pulmonary
edema, COPD/Asthma, and pneumonia
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Questions?