cpap for medical directors

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

[email protected]
mailto:[email protected]:[email protected]


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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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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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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?

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