1. Pre-Hospital CPAP What the EMS Medical Director should know Keith Wesley, MD Wisconsin State EMS Medical Director drwesley@charter.net

2. 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 providers Discuss the methods for implementing pre-hospital CPAP

3. The Goal of CPAP? The Goal of CPAP? Reduce the need for pre- hospital intubation!

4. CPAP vs. Intubation CPAP Non-invasive Easily discontinued Easily adjusted Use by EMT-B Minimal complications Does not require sedation ComfortableIntubation Invasive Intubated stays intubated Requires highly trained personnel Significant complications Can require sedation or RSI Potential for infection

5. 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

6. 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

7. 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

8. 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 bronchodilators Moves extracellular fluid into vasculature Reduces work of breathing

9. 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

10. 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.”

11. Supporting Literature Brochard (French abstract) “ Noninvasive ventilation for acute exacerbations of COPD” “…can reduce the need for intubation, LOS in hospital, and mortality rate”

12. 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

13. 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”

14. 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 training Instruction on assessment most important reason for success

15. 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%

16. 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

17. 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

18. 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 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)? Yes Administer 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

19. 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

20. Wisconsin EMT-Basic Experience Results (preliminary – study completed 11/05)  500 applications of CPAP (114 services)  99% met criteria for CPAP on review of medical director  No field intubations by those services with ALS intercepts  No significant complications  All oxygen sats. improved, dyspnea reduced by average of 50%

21. 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

22. 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

23. 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

24. Indications for CPAP CHF Pulmonary Edema –Near Drowning –Inhalation Exposure COPDAsthmaPneumonia

25. 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? ALS or BLS or BOTH?

26. Items to Consider Equipment –Must be easy to use and portable –Adjustable to patient’s need –Easily started and discontinued –Provide quantifiable and reliable airway pressures –Conservative oxygen utilization –Not interfere with administration traditional therapies for underlying condition

27. 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

28. 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

29. Questions?