EMS CPAP Training

CPAP training developed for my department and in review for possible adoption by the state.

1. State of IdahoState of Idaho
CPAP training ModuleCPAP training Module
DRAFT

2. Revision InformationRevision Information
•Developed October 2008
•Revised November 2008
•For Further Information Please contact:
–Instructor contact information

3. IntroductionIntroduction
•Instructor Introduction
–Experience
–Conflicts of interest
•Device to be used for this training
•This presentation was developed at the
direction of the State of Idaho, Department
of Health and Welfare, Bureau of EMS

4. Special ThanksSpecial Thanks
•The Men and Women of Ada County
Paramedics for their input, advice, and
good sportsmanship in developing this
presentation
•www.adaparamedics.com
•State of Maine EMS
•State of Wisconsin EMS

5. CPAP - BackgroundCPAP - Background
•Continuous Positive Airway Pressure (CPAP)
and related technologies have been in use for
since the 1940’ in respiratory failure.
•It has been largely indicated to assist patients
with primary and secondary sleep apnea, and
globally this continues to be its largest market.
•In recent history (1980’s) it has found wide
acceptance in hospital settings (usually CCU,
ICU, and ERs) for patients suffering varying
degrees of respiratory failure of a wide variety
of origins.
–Acute Pulmonary Edema (APE) most common

6. CPAP - BackgroundCPAP - Background
•CPAP is a non-invasive non-invasive procedure that is
easily applied in the pre-hospital setting.
•CPAP is an established therapeutic
modality, well studied to reduce both
mortality and morbidity.
•CPAP has been shown to be an
preferable alternative to intubation in
some patients.

7. History of CPAPHistory 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)

8. Boussignac CPAP?Boussignac CPAP?
•1973- Boeing 707 crashed near Paris France
–125 fatalities, 3 survivors with severe respiratory
trauma
•CPAP was not well known at the time.
•Mortality for these injuries was 100%
•Dr. Georges Boussignac, decided not to intubate
these patients but to treat them instead with Non
Invasive Ventilation (NIV) and an early form of
CPAP.
–The original CPAP was a bag over the head with
constant air flow at greater than atmospheric
pressure.

9. Types of CPAPTypes of CPAP

10. BoussignacBoussignac

11. OxypeepOxypeep

12. Whisperflow Flow GeneratorsWhisperflow Flow Generators

13. Emergent Products PortO2ventEmergent Products PortO2vent

14. CAREvent® ALS + CPAPCAREvent® ALS + CPAP

15. Physiology of CPAPPhysiology of CPAP

16. Vital TerminologyVital Terminology
•Tidal Volume (Vt)
•Minute Volume (Vm)
•Peak Inspiratory Flow
•Functional Reserve
Capacity (FRC)
•Inspired Oxygen
(FiO2)
•Work of Breathing
(WOB)

18. Airway and Respiratory Anatomy Airway and Respiratory Anatomy
and Physiology and Physiology
•Pathway review
•Oxygenation and Ventilation
•Functional Residual Capacity
•Work of breathing

19. Airway and Respiratory AnatomyAirway and Respiratory Anatomy
•Pathways-

20. Airway and Respiratory AnatomyAirway and Respiratory Anatomy
•Pathways-

21. Question: So why does oxygen Question: So why does oxygen
pass into the blood?pass into the blood?
A: The Pressure Gradient!!!!A: The Pressure Gradient!!!!
Airway and Respiratory PhysiologyAirway and Respiratory Physiology

22. Airway and Respiratory PhysiologyAirway and Respiratory Physiology
•The Pressure gradient!
•Aveolar Air has higher
content of OXYGEN than
venous (deoxygenated)
blood
•Therefore oxygen transfers
fromfrom the air intointo the blood.
•This is called the Pressure
Gradient
–The higher the inspired
oxygen (FiO2) the better
the pressure gradient!

23. Airway and Respiratory PhysiologyAirway and Respiratory Physiology
•Oxygen Saturation Curve
Picture released into public domain by wikipedia

24. Airway and Respiratory PhysiologyAirway and Respiratory Physiology
FRCFRC
•Functional reserve Capacity (FRC) is the volume of air in
the lungs at the end of a normal passivepassive expiration.
–approximately 2400 ml in a 70 kg, average-sized male
•FRC decreases with lying supine, obesity, pregnancy
and anaesthesia.
•Important aim of CPAP is to increase functional residual
capacity (FRC)
–By increasing he FRC, the surface area of the Aveoli is
distended (increased).
–Greater surface area improves gas exchange (oxygenation and
ventilation)
–This improves Spo2/SaO2

25. Airway and Respiratory PhysiologyAirway and Respiratory Physiology
WOBWOB
•Work of breathing (WOB) is respiratory
effort to effect oxygenation and ventilation.
•Important aim of CPAP is to reduce work
of breathing (WOB)

26. Airway and Respiratory PhysiologyAirway and Respiratory Physiology
WOBWOB
•Signs of increased WOB:
–Dyspnea on Exertion (DOE)
–Speech Dyspnea
–Tripoding
–Orthopnea
–Accessory Muscle Use/Restractions
–Lung Sounds
•“Doorway Test”
•Silent Chest!!!!

27. Airway and Respiratory PhysiologyAirway and Respiratory Physiology
WOBWOB
Increased WOB :Increased WOB :
Respiratory FatigueRespiratory Fatigue
Respiratory DistressRespiratory Distress
Respiratory FailureRespiratory Failure
CPAP CPAP reducesreduces WOB WOB

28. Airway and Respiratory PathologyAirway and Respiratory Pathology

29. Airway and Respiratory PathologyAirway and Respiratory Pathology
CHFCHF
•Precipitating Causes
–Non Compliance with Meds and Diet
–Acute MI
–Arrhythmia (e.g. AF)
–Increased Sodium Diet (Holiday Failure)
–Pregnancy (PIH, Pre-eclampsia, Eclampsia)

30. Airway and Respiratory PathologyAirway and Respiratory Pathology
CHFCHF
•Severe resp distress
•Foamy blood tinged
sputum
•Accessory muscle use
•Apprehension, agitation
•Speech Dyspnea
•Diaphoresis
•Bilateral crackles or
Rhales
•Orthopnea (can’t lie
down)
•Paroxysmal nocturnal
dyspnea (PND)
•Cyanosis
•Pedal Edema
•JVD
•Chest pain (possible
co-existent AMI)
•abnormal vitals
(increased B/P; rapid
pulse; rapid & labored
respirations

31. Cardiac Asthma?Cardiac Asthma?
•Fluid leaks into the Interstitial Space
–Airways narrow
–Mimics broncoconstriction seen in asthma
•May actually exacerbate asthma if a co-existing
PMHx
–Produces “Wheezing”

32. Infiltration of Interstitial SpaceInfiltration of Interstitial Space
lNormal
Micro-anatomy
lMicro-anatomy
with fluid
movement.

33. Airway and Respiratory Pathology CHFAirway and Respiratory Pathology CHF
•The following treatments should be done concurrently with CPAP,
patient condition permitting*.
•High Flow Oxygen!!!
•Nitroglycerin *
–0.4 mg sl every 5 minutes;
–0.5-2 inches transdermal
–5-200 mcg/min IV Drip
•Lasix *
–20- 80 mg IV/IM (or double daily dose if already on Lasix)
•Opiates*
–Reduce Anxiety
–Mild Vasodilator
–2.5-5 mg q5 minutes IVP
(* = defer to local protocol or medical control)

34. Airway and Respiratory PathologyAirway and Respiratory Pathology
Asthma and COPDAsthma and COPD
•Obstructive vs Reactive
airways
•Bronchoconstrictive issues
•Poor Gas Exchange
•Accessory Muscle Use/Muscle
Tiring
•CPAP is best reserved for
those patients who are
refractory to normal
interventions, and have a
severe presentation.
–At least TWO doses of
bronchedialtors should be
administered before the
provider initiates CPAP.

35. Airway and Respiratory PathologyAirway and Respiratory Pathology
Asthma and COPDAsthma and COPD
•The following treatments should be done concurrently with
CPAP, patient condition permitting*.
•High Flow Oxygen!!!
•Bronchodilators*
•Albuterol 2.5 mg (0.83% in 3 cc)/ Atrovent 0.5 mg (0.02% in
2.5 cc) nebulized.
•Repeat as needed with Albuterol Only.
•Do not dilute.
• Magnesium Sulfate* (Asthma extremis only)
•IV: 2 g given SLOWLY, diluted.
•Do not give faster than 1 g/minute.
•Epinephrine 1:1,1000
•0.3-0.5 mg IM/SQ for severe refractory bronchospasm
•Use Epinephrine with caution on patients over 65 or with
cardiac history.
•Solu-medrol
•IV/IM: 125 mg
(* = defer to local protocol or medical control)

36. Airway and Respiratory PathologyAirway and Respiratory Pathology
PneumoniaPneumonia
•Infectious process
•Often confused with, or masked by, CHF
•Detailed assessment required
–PMhx, Med list review
–Sputum type/color
–Onset of s/s
–Fever
–Lack of CHF/Afib Hx
•Normal CHF Tx may be ineffective or detrimental
–Nitroglycerine (ineffective)
–Diuretics (detrimental)

37. Airway and Respiratory PathologyAirway and Respiratory Pathology
PneumoniaPneumonia
•CPAP may be of minimal benefit in Pneumonia*.
•High Flow Oxygen!!!
•Bronchodilators*
•Albuterol 2.5 mg (0.83% in 3 cc)/ Atrovent 0.5 mg (0.02% in
2.5 cc) nebulized.
•Repeat as needed with Albuterol Only.
•Do not dilute.
• (* = defer to local protocol or medical control)

38. Airway and Respiratory PathologyAirway and Respiratory Pathology
DrowningDrowning
•CPAP may be beneficial to the
drowning/near drowning patient
•Strongly consider intubation for severe s/s
refractory to CPAP and other treatments

39. Other uses of CPAPOther uses of CPAP
•ARDS
•Acute Respiratory Failure
•Anesthesia (Pre-Op and Post-Op)
•Atelectasis
•Alternative to Mechanical Ventilation
•Weaning from Mechanical Ventilation
•Left Ventricular Failure
•Renal Failure
•Sleep Apnea

40. Physiology of CPAPPhysiology of CPAP

41. Physiology of CPAPPhysiology of CPAP
•Airway pressure maintained at set level
throughout inspiration and expiration
•Maintains patency of small airways and alveoli
–“Stents” small airways open
–“Distends” aveoli
•Improves delivery of bronchodilators
–By up to 80%
•Moves extracellular fluid into vasculature
•Improves gas exchangeImproves gas exchange
•Reduces work of breathingReduces work of breathing

42. Physiology of CPAP : CPAP Physiology of CPAP : CPAP
MechanismMechanism
•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

43. Physiology of CPAP : Physiology of CPAP :
Redistribution of pulmonary Redistribution of pulmonary
edema with CPAPedema with CPAP

44. Physiology of CPAP: HypotensionPhysiology of CPAP: Hypotension
•CPAP increases intrathoracic pressure
•This decreases cardiac output causing
hypotension
•Therefore hypotensive patients may have
are relatively contraindicated with CPAP...

45. Physiology of CPAP : Physiology of CPAP :
Administration of Medications by Administration of Medications by
CPAPCPAP
•CPAP and Nebulizers can be used
together to provide better “penetration” of
nebulizer medications through the
respiratory tract.

46. Use of CPAP by EMSUse of CPAP by EMS

47. Goals of CPAP use in the fieldGoals of CPAP use in the field
•Primary Goals
–Increase amount of inspired oxygen (FiO2)
–Increase the SpO2 and PaO2 of the patient
–Decrease the work load of breathing (WOB)
–To reduce overall mortality
•Secondary Goals:
–Reduce the need for emergent intubations of
the patient
–Decrease hospital length of stay (LOS)

48. CPAP vs. IntubationCPAP vs. Intubation
CPAP
•Non-invasive
•Easily discontinued
•Easily adjusted
•Use by EMT-B (in some
states)
•Minimal complications
•Does not (typically)
require sedation
•Comfortable
Intubation
•Invasive
•Intubated stays intubated
•Requires highly trained
personnel
•Significant complications
•Can require sedation or
RSI
•Potential for infection

49. Key Point:Key Point:
•This module discusses CPAP in patients >8
years of age
•CPAP has been safely used in children, infants,
and neonates in the in-hospital and critical care
settings
•Local protocols may allow use in children and
infants
–Appropriate sized equipment mandatory
–Risk increases
•Consult medical control and local protocols

50. IndicationsIndications
For consideration (for patients <8) in moderate to severe
respiratory distress secondary to:
–CHF/APE
–Acute Respiratory Failure
–asthma/reactive airway disease,
–near drowning,
–COPD,
–acute pulmonary edema (cardiogenic and non cardiogenic),
–pneumonia who present with any of the following:
–Pulse oximetry < 88% not improving with standard therapy
–ETCO2 > 50mmHg
–Accessory muscle use / retractions
–Respiratory rate > 25
–Wheezes, rales, rhonchi
–Signs of respiratory fatigue or failure

51. A note on misdiagnosisA note on misdiagnosis
•There is a significant misdiagnosis rate of
CHF in the field, most commonly confused
with pneumonia
•CPAP still demonstrated significant
improvement in other (non-CHF/APE)
respiratory emergencies
–Risks are greater greater in non CHF/APE
–CPAP Max Pressures are lower lower non
CHF/APE
–Caution is required required non CHF/APE

52. 2003 Helsinki EMS Looked at “patients in Acute Severe
Pulmonary Edema (ASPE)”
Study Group: Study Group: 121121
Confirmed CHF:Confirmed CHF: 3838 (32%)(32%)
Miss- DX:Miss- DX: 83 83 (68%)(68%)
Non CHF Patients that got Non CHF Patients that got
better with CPAPbetter with CPAP:: 3434 (28%)(28%)
Non CPAP mortalityNon CPAP mortality (17.8%)(17.8%)
CPAP MortalityCPAP Mortality (8%)(8%)
Other Notes:
•Confirmed by MNP
•Treated with Low-Mid FiO2, Nitrates. No Lasix
•4 intubated in field (3%)
(Kallio, T. et al. Prehospital Emergency Care. 2003. 7(2) )

53. Contraindications/Exclusion CriteriaContraindications/Exclusion Criteria
•Physiologic
–Unconscious, Unresponsive, or inability to protect airway.
–Inability to sit up
–Respiratory arrest or agonal respirations (Consider Intubation)
–Persistent nausea/vomiting
–Hypotension- Systolic Blood Pressure less than 90 mmHg
–Inability to obtain a good mask seal
•Pathologic
–Suspected Pneumothorax
–Shock associated with cardiac insufficiency
–Penetrating chest trauma
–Facial anomalies /trauma/burns
–Closed Head Injury
–Has active upper GI bleeding or history of recent gastric surgery
–Vomiting

54. CautionsCautions
•History of Pulmonary Fibrosis
•Claustrophobia or unable to tolerate mask (after
initial 1-2 minutes)
–Coaching essential
–Consider mild sedation
•Has failed at past attempts at noninvasive
ventilation
•Complains of nausea or vomiting
•Has excessive secretions
•Has a facial deformity that prevents the use of
CPAP

55. AdministrationAdministration
•CPAP is measured in cm/
H2O
•Start with device in the
lowest setting, and titrate
upward.
•Initial dose at 0-2
cm/H2O
•Titrated up to*:
–10 cm/H2O MAX for CHF
or,
–5 cm/H2O MAX for COPD,
near drowning, and
respiratory failure form
other causes.
•(* = defer to local protocol or medical control)

56. Selling CPAP?Selling CPAP?
•Placing CPAP is an anxiety inducing event
in the hypoxic respiratory distressed
patient!
•Verbally calming, coaching, and preparing
(AKA: Selling) your patient on CPAP is
essential
•Similar to calming a hyperventilation
patient

57. ComplicationsComplications
•CPAP may drop BP due to increased intrathoracic pressure.
–A patient must have a systolic BP of at least 90mmHg to be a candidate
for CPAP
–Increased Intrathoracic pressure means decreased ventricular filling and
increased afterload, thus decreasing cardiac output and blood pressure.
–Providers should be comfortable giving a CPAP patient NTG If they are
too hypotensive for NTG, then they are too hypotensive for CPAP.
•Risk of pneumothorax
–Increased intrathoracic pressure = increased risk
–Higher in Asthmatics and COPD
•Gastric Distention, and vomiting
–Strongly consider placement of a gastric tube (if in scope of practice)
•Risk of corneal drying
–High volumes of air blowing at eyes, especially on long transports.

58. Discontinuing of CPAPDiscontinuing of CPAP
•CPAP therapy needs to be continuous and should not
be removed unless the patient:
–cannot tolerate the mask, success of tolerance to the
treatment increased with proper coaching by EMS
crew
–requires suctioning or airway intervention,
–experiences continued or worsening respiratory
failure,
–Develops severe hypotension
–or a pneumothorax is suspected.
•Intermittent positive pressure ventilation and/or
intubation should be considered if patient is removed
from CPAP therapy.

59. KEY POINT:KEY POINT:
CPAP will not cure all patients!
Some patients just really want a tube!
““Don’t give up to early but know when Don’t give up to early but know when
to give up”to give up”

60. DocumentationDocumentation
•“Dosage”
–CPAP level ®(10cmH2O)
–FiO2 ®(100%)
•Subjective response to therapy
•Objective response to therapy
–Lung Sounds,
–Work of Breathing
•SPO2
•Nasal ETCO2
•SpO2 q5 minutes
•Vital Sign q5 minutes
•Any adverse reactions
•Justification for sedation,
intubation, or discontinuation
of CPAP. Be specific.

61. Documentation: Modified Borg Documentation: Modified Borg
ScaleScale
•“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

62. EMS System Implementations and EMS System Implementations and
ConsiderationsConsiderations
•Types of CPAP
•Oxygen source and supply
–Size of tanks
–Availability of “full” tanks
–Availability of appropriate regulators
•Duration of transport
•Destination Hospital
•Turnaround time and transfer of care

63. CPAP and IntubationCPAP and Intubation
•Intubation will be inevitable in some patients regardless
of the use of CPAP, and the paramedic must be
prepared for rapid intervention by RSI/MAI or other
means as feasible.
•Indications to proceed to ET placement are (not all
inclusive):
–Deterioration of mental status
–Increase of the EtCO2
–Decline of SpO2
–Progressive fatigue
–Ineffective tidal volume
–Respiratory or cardiac arrest.

64. POST POST
•POST does not specifically address
CPAP, but is likely permissible since it is
both palliative and noninvasive.

65. Research ReviewResearch Review

66. Research ReviewResearch Review
•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

67. Research ReviewResearch Review
•CPAP therapy can improve A.P.E. patients in
Minutes.
•Has been compared to D50 in hypoglycemic patients
•“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)
•2000 Cincinnati EMS looked at “CHF patients in
imminent need of intubation”
–19 patients included, CPAP administered
–*Pre- and post-therapy pulse ox increased from 83.3% to 95.4%
–*None of the patients were intubated in the field
–*Average hospital stay reduced from 11 days to 3.5 days

68. “CPAP is to APE like D50 is to
insulin shock”
-Russell K. Miller Jr, MD, FACEP

69. Research ReviewResearch Review
•CPAP in COPD:
–85 patients in a single ICU over a study period.
–Randomized control group
•CPAP significantly reduced need of ETT in COPD patients by 48%48%
•Complications were decreased by 32%32%
•Mortality Decreased by 20%Mortality Decreased by 20%
•“CONCLUSIONS. In selected patients with acute exacerbations of
chronic obstructive pulmonary disease, noninvasive ventilation can
reduce the need for endotracheal intubation, the length of the
hospital stay, and the in-hospital mortality rate. “
•Brochard L, Mancebo J, Wysocki M, Lofaso F, Conti G, Rauss A, Simonneau G,
Benito S, Gasparetto A, Lemaire F, et al Noninvasive ventilation for acute
exacerbations of chronic obstructive pulmonary disease. N Engl J Med
1996;334(11):743. .

70. Research Review BiPap vs. CPAPResearch Review BiPap vs. CPAP
•“Though BLPAP (BiPAP) has theoretical advantages
over CPAP, there are questions regarding its safety in a
setting of CHF. The Key to success in using NIV to treat
severe CHF is proper patient selection, close patient
monitoring, proper application of the technology, and
objective therapeutic goals. When used appropriately,
NIV can be a useful adjunct in the treatment of a subset
of patients with acute CHF at risk for endotracheal
intubation.”
•Reviews in Cardiovascular Medicine, vol. 3 supl. 4 2002, “Role of
Noninvasive Ventilation in the Management of Acutely Decompensated
Heart Failure”

71. Research Review: BiPAP vs Research Review: BiPAP vs
CPAPCPAP
•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

72. Research review: Pre-hospital Research review: Pre-hospital
CPAPCPAP
•PEC 2000 NAEMSP Abstract, “Pre-hospital use of CPAP
for presumed pulmonary edema: a preliminary case
series”, Kosowsky, et. al.
•19 patients
•Mean duration of therapy 15.5 minutes
•Oxygen sat. rose from 83.3% to 95.4%
•None were intubated in the field
•2 intubated in the ED
•5 subsequently intubated in hospital
•“Pre-hospital CPAP is feasible and may avert the need
for intubation”

73. ReviewReview
•CPAP is not a substitute for patients
needing IPPV or intubation.
•CPAP works best when used in
conjunction with other therapies.
•CPAP doses start at ZEROZERO and titrate up
–Max of 10 cmH2O for APE
–Mac of 5 cmH2O for other causes
•CPAP is effective in COPD when
CAREFULLYCAREFULLY used.

74. Key Points of CPAPKey Points of CPAP
•CPAP, while very
beneficial in many
patients, is not risk is not risk
freefree.
–Pneumothorax
–Regurgitation and
aspiration
–hypotension

75. Review local protocol or local Review local protocol or local
Medical Director considerationsMedical Director considerations

76. Questions?Questions?

77. Device specific orientation and Device specific orientation and
skills practiceskills practice
Followed by skills check off and a
written test!