CPAP Pilot Training

CPAP Pilot Training

Dan Batsie

dbatsie@emcc.edu



Acknowledgements

•Dave Pavlakovich, RRT,

•University of Texas Medical Branch, Galveston, TX

•Dave Henning, NREMT-P, CCP

•Gold Cross Ambulance Service, Manasha, WI

•Dr. John Burton, MMC

•Dr. John Alexander, MMC

•Dr. Matt Sholl, MMC

•Dr. John Saucier, MMC



Functional Residual Capacity



“Also known as FRC, this is the lung volume at the end of a normal expiration, when the

muscles of respiration are completely relaxed; at FRC and at FRC only, the tendency of the

lungs to collapse is exactly balanced by the tendency of the chest wall to expand.”

http://oac.med.jhmi.edu/res_phys/Dictionary.HTML



Peak Inspiratory Flow



“Take a deep breath in: you have probably just inspired 1 liter of air in about 1 second. Your

inspiratory flow rate is thus approximately 60 liters per minute during this deep breath. Every

breath you take varies in depth and volume, but if you were in respiratory failure you may well

require flow rates of this magnitude (or more). To be guaranteed a FiO 2 appropriate to your

flow demand, a fixed performance flow-generating device must be placed at your airway with

a flow rate of 60 or so liters of oxygen-air (mixed as required) to satisfy demand. To be a

fixed performance device, the gas flow must exceed the patient’s peak inspiratory flow.



http://www.ccmtutorials.com/rs/oxygen/page13.htm





Common Dysfunctions



COPD

*Obstructive Issues

*Gas Exchange Issues

*Muscle Tiring



Definition of CHF

“The situation when the heart is incapable of maintaining a cardiac output dequate to

accommodate metabolic requirements and the venous return.”

-E. Braunwald



APE

*Pressure Changes and fluid shift

*VQ Mismatch

*Distress and sympathetic discharge

Diagnosis of APE

•Pt with symptoms of heart failure - shortness of breath and leg swelling.

•Physical exam findings for heart failure - lungs: rales, legs: edema, neck: jvd

•Chest XRay findings for CHF

•Findings of systolic or diastolic dysfunction: Echocardiograms: Low ejection fraction/poor

contractility (hypocontractility)



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?



Continuous Positive Airway Pressure

What Is CPAP

“Breathing Against A Threshold of Resistance”

“Pneumatic Splinting of Airways”

“Oxygen Therapy In It’s Most Efficient Form”



In Our Pilot….

-Mask

-Tubing

-Gas Source

-PEEP Regulation

-Generator



-Air is mixed with oxygen via a venturi system or with a “Downs Flow Generator”



-Resistance is regulated with a PEEP valve.



Effects of CPAP



-Increased Functional Residual Capacity

-Reduced Work of Breathing

-Increased Oxygen Diffusion Across Alveolar Membrane

-Increased Alveolar Surface Area



In Acute Pulmonary Edema

*Changes Pressure Gradients

*Reduces Work of Breathing/Sympathetic Discharge

*Can Decrease Preload



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)

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



What about misdiagnosis?



Accuracy of Diagnosis: CHF

EMS: 50-65%

Emergency Doc: 65-80%

Cardiologist: 80-85%

-John Burton CHF in EMS 2005



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))



Keep in mind Helsinki

-34 (non chf) of 121 still got better

There is sparse research & anecdotal evidence for use in other etiologies…



O2 Saturation change in >10 min. Transports

(Average transport time = 14±3 N=20)

Initial O2 Sat.= 78±12

5 minute O2 Sat.= 92±6

Average Change= 14+%



O2 Saturation change in 18 yrs  

b. Patent Airway  

c. Acute Respiratory Insufficiency/Impending Respiratory Failure  

d. Suspected Pulmonary Edema  



VII. Does this patient need to be excluded from CPAP? Yes No

a. Altered Mental Status (Excessive agitation or somnolence)  

b. Hypotension (SBP < 100)  

c. Respiratory Distress Associated With Trauma  

d. Facial Trauma or Impossible Facial Seal On Mask  

e. Immediate Need for Endotracheal Intubation  



VIII. Medical Control Requests Yes No Dose Given/Duration

a. Nitroglycerin   _____________

b. Fentanyl   _____________

c. Lasix   _____________

d. CPAP   _________mins

e. Other ________________   _____________

f. Other ________________   _____________



IX. CPAP System Used (Circle One) Whisper Flow - OxyPeep - Port-o-Vent - Boussignac







-Over-

X. 5 Minute Assessment (Post CPAP Application)

a. Patient Respiratory Distress Level (0-10 Scale) ____________

b. Vital Signs

1. Respiratory Rate ____________

2. Pulse Rate ____________

3. Blood Pressure ______/_____

4. Pulse Oxygenation __________%





XI. Patient Condition Upon Arrival to ED

A Lot Worse___ A Little Worse___ Same___ A Little Better___ A Lot Better___



Patient Respiratory Distress Level (0-10 Scale) ____________



XII. Paramedic Ease of Use of CPAP

Very Difficult___ Somewhat Difficult___ Neutral___ Somewhat Easy___Very Easy___



XIII. Patient Tolerance of CPAP

Very Poor___ Poor___ Neutral___ Good___ Very Good___



XIV. Patient Required Pre-Hospital Intubation? Yes No

CHF Hospital Data Collection Sheet

1. Date of Admission________________________



2. Hospital Name ______________________________________________



3. Initial Triage Assessment

a. Respiratory Rate _____________

b. Pulse Rate _____________

c. Blood Pressure ______/______

d. Pulse Oxygenation ___________%



4. ED Therapies Administered Yes No Dose Given/Duration

e. SL Nitroglycerin   _____________

f. IV Nitroglycerin   _____________

g. Transdermal Nitroglycerin   _____________

h. Morphine   _____________

i. Lasix   _____________

j. Captopril   _____________

k. Metoprolol   _____________

l. CPAP   _________mins

m. BiPAP (Duration of time)   _________mins

n. Other ________________   _____________

o. Other ________________   _____________



5. Patient Required Endotracheal Intubation in ED? Yes No



6. Patient Disposition from E.D. Yes No

p. Admitted to Floor/Telemetry  

q. Admitted to ICU  

r. Discharged  

s. Expired  



7. Admission Diagnosis ____________________________________________________



8. Patient Required Endotracheal Intubation in hospital? Yes No



9. Length of Stay

t. ICU ______________

u. Floor/Telemetry ______________



10. Patient Disposition from Hospital Yes No

v. Discharged on Ventilator  

w. Discharged without Ventilator  

x. Deceased  



11. Discharge Diagnosis _____________________________________________________