1. Prehospital CPAP
Provider Training

2. Acknowledgements Dave Pavlakovich, RRT,
University of Texas Medical Branch, Galveston, TX
Dave Henning, NREMT-P, CCP
Gold Cross Ambulance Service, Manasha, WI

3. Topics For Today -Overview of Respiratory Mechanics
-Most Common Respiratory Dysfunctions
-What is CPAP?
-How Can We Use CPAP?
-Exclusions
-Protocols
-Assessment
-Data Collection
-Practical

4. Respiratory Mechanics
Components of the Airway
The function of this section is assure that students understand the physiology of respiration and in particular the physiology that CPAP will effect. This lesson plan will employ later the terminology discussed in this section so it is important to ensure comprehension.

5. Respiratory Mechanics
Oxygenation and Ventilation
Emphasize the two separate components acting theoretically independent of one another.

6. Respiratory Mechanics
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.”

7. Respiratory Mechanics
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 FiO2 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.

8. Obstructive vs. Restrictive Disorders
Common Dysfunctions
Obstructive vs. Restrictive Disorders
Obstructive = air impeded from moving through airways. Increased airway resistance causing reduced expiratory airflow rates
Restrictive = limited lung expansion, reduced lung volumes

9. Common Dysfunctions COPD *Obstructive Issues *Gas Exchange Issues
*Muscle Tiring
Acute vs. Chronic, reversible vs. irreversible
Obstructive disorder.
Can be oxygenation or ventilation disorder or both.

10. *Pressure Changes and fluid shift *Distress and sympathetic discharge
Common Dysfunctions
Acute Pulmonary Edema
*Pressure Changes and fluid shift
*VQ Mismatch
*Distress and sympathetic discharge
Restrictive Disorder
Breathing can be like “Like blowing up a balloon for the first time, every time.”
Self PEEPing trying to keep alveoli open

11. Diagnosis of APE: Symptoms Physical exam findings
Acute onset shortness of breath
Physical exam findings
Rales, legs
Pedal edema
JVD
Chest XRay findings for CHF
Echocardiograms: Low ejection fraction/poor contractility (hypocontractility)
Consider other “cardiac related symptomology to be suspicious
C/P, Acute onset N/V, Syncope

12. 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?
Be aware that a lack of rales does not rule out APE
Burton , J. CHF in EMS 2005

13. What Is CPAP Continuous Positive Airway Pressure
“Breathing Against A Threshold of Resistance”
“Pneumatic Splinting of Airways”
“Oxygen Therapy In It’s Most Efficient Form”

14. In Our Program…. -Mask -Tubing -Gas Source -PEEP Regulation -Generator
What Is CPAP
In Our Program….
-Mask
-Tubing
-Gas Source
-PEEP Regulation
-Generator
At this point a devices should be demonstrated pointing out the specific components
Mask
Tubing
Gas source
PEEP Valve (if present)
Positive End Expiratory Pressure
The increase in pressure at exhalation
A PEEP valve regulates this to assure continuous airway pressure
Often this valve is nothing more than a simple “pop-off” valve
PEEP valves should be adjusted to 10mmHg for MEMS
Downs flow generator/venturi system (if present)

15. What Is CPAP In Our Program….
-Air is mixed with oxygen via a venturi system or with a “Downs Flow Generator”
At this point a devices should be demonstrated pointing out the specific components
Mask
Tubing
Gas source
PEEP Valve (if present)
Positive End Expiratory Pressure
The increase in pressure at exhalation
A PEEP valve regulates this to assure continuous airway pressure
Often this valve is nothing more than a simple “pop-off” valve
PEEP valves should be adjusted to 10mmHg for MEMS
Downs flow generator/venturi system (if present)

16. What Is CPAP
-Resistance is regulated with a positive end expiratory pressure (PEEP) valve.
PEEP Valve (if present)
Positive End Expiratory Pressure
The increase in pressure at exhalation
A PEEP valve regulates this to assure continuous airway pressure
Often this valve is nothing more than a simple “pop-off” valve
PEEP valves should be adjusted to 10mmHg for MEMS

17. What Is CPAP

18. Effects of CPAP -Increased Functional Residual Capacity
-Reduced Work Of Breathing
-Increased Oxygen Diffusion Across Alveolar Membrane
-Increased Alveolar Surface Area
Increases functional residual capacity.
The pressure simply puts more air in the lungs
Increases alveolar surface area available for gas exchange.
By preventing atelectasis, more alveoli are available
Increases oxygen diffusion across alveolar membrane.
Pressure pushes oxygen
Reduces work of breathing.
The pneumatic splint of CPAP prevents the patient from having to exert energy to do it themselves

19. Effects of CPAP Acute Pulmonary Edema Changes Pressure Gradients
Reduces Work of Breathing Sympathetic Discharge
Can Decrease Preload
CPAP in Acute Pulmonary Edema
Changes pressure gradient, prevents the influx of fluid.
Reduces work of breathing may help avoid intubation, reduces sympathetic discharge.
CPAP therapy can improve A.P.E. patients in 90 seconds
CPAP should be initiated in APE regardless of transport time
Can decrease preload.
Positive pressure in chest can impact filling of the heart and therefore drop preload
Beware a subsequent drop in cardiac output (evidenced by a fall in BP)

20. 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 Data review Chest 1998; 114(4): )

21. “CPAP is to APE like D50 is to insulin shock”
How We Can Use CPAP
Acute Pulmonary Edema
“CPAP is to APE like D50 is to insulin shock”
Russell K. Miller Jr, MD, FACEP
Can reduce the need of intubation in 50-90%
Can alleviate symptoms in as fast as 90 seconds

22. *What about misdiagnosis?
But Maine has many inexperienced providers…
*What about misdiagnosis?

23. 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 (2) )
We note a European study here that noted improvement after CPAP administration even though there was a high misdiagnosis rate (84/121).
Kallio, T. et al. Prehospital Emergency Care (2)
The purpose of this slide is to encourage providers to be aggressive with CPAP but at the same time instructors should restate that CPAP is intended for the APE and not intended as a first line for other respiratory disorders.

24. -34 (non chf) of 121 still got better
Keep in mind Helsinki
-34 (non chf) of 121 still got better
There is sparse research & anecdotal evidence for use in other etiologies…
Because it can be truly therapeutic CPAP is intended for the APE patient. Although other respiratory disorders may see benefit from the more palliative effects, it should be noted that CPAP IS NOT a substitute form bronchodilator therapy in broncho-constrictive events

25. CPAP IS NOT MECHANICAL VENTILATION!
Limitations of CPAP
CPAP IS NOT MECHANICAL VENTILATION!
Instructors MUST emphasize that a patient must have a patent airway and reasonable respiratory effort to be a candidate for CPAP.
CPAP is NOT a ventilator and those patients needing such mechanical ventilation or airway control are NOT candidates for CPAP

26. Limitations of CPAP Other Limitations…
-Increased Intrathoracic Pressure Can Produce Hypotension
-Psychological Effects
-Pneumothorax
-Corneal Drying
A patient must have a systolic BP of at least 100mmHg to be a candidate for CPAP
Providers should be comfortable giving a CPAP patient NTG-If they are too hypotensive for NTG, then they are too hypotensive for CPAP.

27. Oxygen Demand Time = (f X PSI) / LPM
Limitations of CPAP
Oxygen Demand
Time = (f X PSI) / LPM
Tanks at 1000 PSI
“D” (f = 0.16) = 1-2 Minutes
“E” (f = 0.28) = 2-4 Minutes
“M” (f = 1.59) = Minutes
“H” (f = 3.18) = Minutes

28. -APE -Acute respiratory insufficiency
CPAP Indication
-APE
-Acute respiratory insufficiency

29. CPAP Indication
Acute respiratory insufficiency will be defined as moderate/severe respiratory distress of 5 word or less dyspnea concurrent with signs and symptoms of hypoxia (cyanosis, pulse oximetry readings of less than 90%, etc.), and/or accessory muscle use.

30. CPAP Exclusions -Patient < 18 -Unstable Airway
-Traumatic Etiology of Respiratory. Distress
-Severe Altered Mental Status
-Facial Trauma or Impossible Face Seal
Note that it is anticipated that some CPAP candidates will have altered mental status. However providers should carefully assess any mental status change to assure it has not impacted airway patency or respiratory effort. Patients with such severe alterations in mental status are not candidates for CPAP.

31. *Intermediate and Above-Standing Order
CPAP Protocol
*Intermediate and Above-Standing Order

32. CPAP Protocol APE *MEMS Protocols Plus… -Medical Control -CPAP Option
*Reassess, Reassess, Reassess!
Review CPAP as an addition to the MEMS Acute Pulmonary Edema protocol
Note that CPAP does not take the place of pharmacology
Note that although CPAP is listed at the end of a linear list, it need not be interpreted that all other interventions must be completed prior to its use. Providers should use good clinical judgment to determine at what point in the course of the various therapies CPAP should be initiated.

33. Psychological Therapy Address the emotional component
CPAP Protocol
Psychological Therapy
Address the emotional component
Don’t give up too early but know when to say when.
Claustrophobia is a common complaint with CPAP masks
Don’t give up to early but know when to give up
It is recommended that in the case of a claustrophobic patient that they be allowed to hold the mask and remove it if necessary. It is common that as the benefits are felt, patients will be inclined to keep the mask on their face. Straps can then be attached as the patient becomes more comfortable
Note that some patients will not tolerate the mask and should not be forced.

34. Reassess, Reassess, Reassess!
Slowing respirations do not necessarily indicate improvement
Be cognizant of hypotension.
As usual, be aggressive with airways.
Aggressive airway evaluation and control.
Not all patients will improve
Providers must be prepared to discontinue CPAP and initiate more aggressive steps in decompensating patients.
**ALERT** for circumstances in which the patient continues to deteriorate despite CPAP and/or medicative therapy, terminate CPAP administration and perform BVM ventilation and/or endotracheal intubation if necessary.

35. MEMS Approved CPAP Systems
Whisper Flow, Oxypeep,
This section is designed for the instructor to provide a more detailed review of the selected system. This session precludes a psychomotor session for the students to at this point psychomotor objectives should be reviewed.
Utilizing the selected CPAP system and following manufacturers guidelines, instructors should review:
Packaging
Assembly (if necessary)
Adjustment (as appropriate for the selected device)
Oxygen liter flow and connection
PEEP valves
Downs flow generator controls
Venturi controls
Application to a patient
Securing the device including strap placement
Notes
During this section the instructor should demonstrate each of the above criteria. For larger groups, assistant instructors and additional devices may be necessary.
It is typical for manufacturers to supply standard competency sheets for using their device. Sales representatives may be able to provide such sheets for use in this class.
Instructors must be familiar with the specific operation of the device they are demonstrating

36. MEMS Approved CPAP Systems
Port-O-Vent, Boussignac
This section is designed for the instructor to provide a more detailed review of the selected system. This session precludes a psychomotor session for the students to at this point psychomotor objectives should be reviewed.
Utilizing the selected CPAP system and following manufacturers guidelines, instructors should review:
Packaging
Assembly (if necessary)
Adjustment (as appropriate for the selected device)
Oxygen liter flow and connection
PEEP valves
Downs flow generator controls
Venturi controls
Application to a patient
Securing the device including strap placement
Notes
During this section the instructor should demonstrate each of the above criteria. For larger groups, assistant instructors and additional devices may be necessary.
It is typical for manufacturers to supply standard competency sheets for using their device. Sales representatives may be able to provide such sheets for use in this class.
Instructors must be familiar with the specific operation of the device they are demonstrating

37. Oxy-PEEP Oxygen Diluter with PEEP
CPAP SYSTEMS
Oxypeep
Oxy-PEEP Oxygen Diluter with PEEP
FiO2(O2)
InputO2 lpm
Total Flowlpm
PEEP CmH2O 32 15
107
0-20 40 62 50 41 60
Flush 81 80 54 95 43

38. Boussignac CPAP SYSTEMS
This section is designed for the instructor to provide a more detailed review of the selected system. This session precludes a psychomotor session for the students to at this point psychomotor objectives should be reviewed.
Utilizing the selected CPAP system and following manufacturers guidelines, instructors should review:
Packaging
Assembly (if necessary)
Adjustment (as appropriate for the selected device)
Oxygen liter flow and connection
PEEP valves
Downs flow generator controls
Venturi controls
Application to a patient
Securing the device including strap placement
Notes
During this section the instructor should demonstrate each of the above criteria. For larger groups, assistant instructors and additional devices may be necessary.
It is typical for manufacturers to supply standard competency sheets for using their device. Sales representatives may be able to provide such sheets for use in this class.
Instructors must be familiar with the specific operation of the device they are demonstrating

39. Boussignac CPAP SYSTEMS
This section is designed for the instructor to provide a more detailed review of the selected system. This session precludes a psychomotor session for the students to at this point psychomotor objectives should be reviewed.
Utilizing the selected CPAP system and following manufacturers guidelines, instructors should review:
Packaging
Assembly (if necessary)
Adjustment (as appropriate for the selected device)
Oxygen liter flow and connection
PEEP valves
Downs flow generator controls
Venturi controls
Application to a patient
Securing the device including strap placement
Notes
During this section the instructor should demonstrate each of the above criteria. For larger groups, assistant instructors and additional devices may be necessary.
It is typical for manufacturers to supply standard competency sheets for using their device. Sales representatives may be able to provide such sheets for use in this class.
Instructors must be familiar with the specific operation of the device they are demonstrating

40. *Medical Control Requests
CPAP Documentation
Necessary Elements
 *Initial Assessment
*System Utilized
*Medical Control Requests
*5 Minute Assessment
*Arrival Condition
Instructors should note that MEMS and or the Regional Offices may require further documentation as part of ongoing State and or Regional Quality Assurance

41. Documentation Modified Borg Scale “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
Note that this is the “modified, modified Borg Scale”
Emphasize that this is similar to the chest pain scale we already use and will not necessitate talking in patients.

42. Practical Session
Sample devices should be distributed and small groups should be facilitated to assure each student can demonstrate the following psychomotor objectives for the specific device:
Demonstrate the correct assembly prior to patient administration
Given a CPAP device, demonstrate proper placement on a simulated patient (to include proper mask seal)
Notes
Although students must demonstrate appriopriate psychomotor competency, instructors should note that students should continue to practice and increase their comfort level with devices beyond the time frame of this class.
Instructors should note that there is more than one approved CPAP device in MEMS and regardless of what device was demonstrated in this session, providers must be competent with their service’s selected device prior to utilizing it in a patient care setting.
Any necessary remediation plan will be developed by the instructor.

43. QUESTIONS?