Pre-Hospital CPAP What the EMS Medical Director should know by eot15664

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									 Pre-Hospital CPAP

What the EMS Medical
Director should know
          Keith Wesley, MD
 Wisconsin State EMS Medical Director
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 providers
Discuss the methods for implementing
pre-hospital CPAP
The Goal of CPAP?

Reduce the need for pre-
  hospital intubation!
        CPAP vs. Intubation
         CPAP                       Intubation
Non-invasive                Invasive
Easily discontinued         Intubated stays intubated
Easily adjusted             Requires highly trained
Use by EMT-B                personnel
Minimal complications       Significant complications
Does not require sedation   Can require sedation or
Comfortable                 RSI
                            Potential for infection
               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
– Intubated patients have 4 times the mortality of non-
  intubated patients
            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
             The Problem
– 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
      Physiology of CPAP
Airway pressure maintained at set level
throughout inspiration and expiration
Maintains patency of small airways and
Improves gas exchange
Improves delivery of bronchodilators
Moves extracellular fluid into vasculature
Reduces work of breathing
      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
          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 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.”
       Supporting Literature
  Brochard (French abstract) “ Noninvasive
  ventilation for acute exacerbations of
“…can reduce the need for intubation, LOS
  in hospital, and mortality rate”
          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
         Pre-hospital CPAP
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”
       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 &
– 2 hours clinical training
Instruction on assessment most important
reason for success
           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%
Wisconsin EMT–Basic 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 collection
Compared to same data collected by ALS
services during same period
Wisconsin EMT–Basic Experience
Required data collection
 – Criteria used to apply CPAP
 – Absence of contraindications
 – Q 5 min. vital signs including oxygen sats.
 – Subjective dyspnea score
Because EMT–Basics don’t diagnose a
unique “Respiratory Distress” protocol
used to capture patients
         Adult Respiratory Distress Protocol
                              (Age greater than 12)

       Routine Medical Assessment

         2 LPM via Nasal Cannula
   Titrate to maintain Pulse ox of >92%

  Is Patient a candidate for Mask CPAP?
       -Respiratory Rate > 25 / min           Yes
   -Retractions or accessory muscle use               See Mask CPAP Protocol
        -Pulse ox < 94% at any time

     Is the Patient wheezing and/or does       Yes
                                                       Administer Albuterol /
the Patient have a history of Asthma/COPD?             Atrovent by Nebulizer


Does the Patient have rales and/or does the                If Basic IV Tech:
 Patient have a history of congestive heart              Administer 1 spray
              failure (CHF)?                            sublingual NTG every
                                                         5 minutes as long as
                           No                         systolic BP is greater than
        Contact Medical Control
  Consider ALS Intercept and Transport
                                    Mask CPAP for EMT-Basic
                                          Asses Patient, record vital signs
      CPAP Inclusion Criteria           and pulse ox before applying oxygen
    (2 or more of the following)
-Retractions or Accessory muscle use
  -Respiratory Rate > 25 / minutes       Does the Patient meet two or more
    -Pulse Ox < 94% at any time                 Inclusion Criteria?

     CPAP Exclusion Criteria
    -Unable to follow commands
    -Vomiting or active GI bleed                                              Yes
                                            Does the Patient meet any                       Continue standard BLS
   -Major trauma / pneumothorax
                                              Exclusion Criteria?                         Respiratory Distress Protocol
  Conditions Indicated for CPAP                             No
     Congestive Heart Failure
         COPD / Asthma                           Administer CPAP                       Reassess patient, vital signs, and
           Pneumonia                        5 cm H2O of pressure AND                respiratory distress scale every 5 min.

                                                                                         Patient condition is deteriorating
      Patient condition is stable            Notify Medical Control
                                                                                                 Decreasing LOC
            or improving                     Consider ALS Intercept
                                                                                               Decreasing Pulse Ox
                                                and continue BLS
                                           Respiratory Distress Protocol
          Continue CPAP                                                                       Notify Medical Control
       Reassess patient every
                                        Complete CPAP Data Form and
             5 minutes
                                       submit to service Medical Director
                                        for each patient placed on CPAP                          Remove CPAP
                                                                                              Apply BVM Ventilation
Wisconsin EMT-Basic Experience

Results (preliminary – study completed
 500 applications of CPAP (114 services)
 99% met criteria for CPAP on review of medical
 No field intubations by those services with ALS
 No significant complications
 All oxygen sats. improved, dyspnea reduced by
  average of 50%
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
 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
 Eau Claire Fire Experience
50 applications
No field intubations
Initial CO2 levels average 62
All patients CO2 levels increased during
first 5 minutes
CO2 levels increasing more than 10
positively predicted CPAP failure
     Indications for CPAP
Pulmonary Edema
– Near Drowning
– Inhalation Exposure
        Items to Consider
How good is current care for respiratory
– Aggressive nitrates for CHF?
– Aggressive use of bronchodilators?
– Pre-hospital and hospital intubation rate?
Requires active medical oversight
– Airway management is a sentinel event
         Items to Consider
– Must be easy to use and portable
– Adjustable to patient’s need
– Easily started and discontinued
– Provide quantifiable and reliable airway
– Conservative oxygen utilization
– Not interfere with administration traditional
  therapies for underlying condition
         Items to Consider
Oxygen concentration
– Fixed versus Variable rates
    Fixed rates are either 35% or 100% in current
    models but actual concentration will be less
    depending on leaks and minute ventilation
    Variable rate increases chance of inadequate
    oxygen supply
– Pressure level
    Most studies show 5cm H20 sufficient
    Complication rate goes up with pressure
CPAP is a non-invasive procedure that is
easily applied and can be easily
discontinued without untoward patient
CPAP is an established therapeutic
Data supports its use in CHF, pulmonary
edema, COPD/Asthma, and pneumonia

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