ALS / BLS CONTINUING EDUCATIONAMY GUTMAN MD ~ EMS MEDICAL DIRECTOR

Continuous Positive Continuous Positive Airway Pressure DevicesAirway Pressure Devices

OverviewOverview

Review CPAP goals & physiology

Indications & contraindications

EBM literature review

OEMS protocol & medical director review

What is CPAP (Continuous What is CPAP (Continuous Positive Airway Pressure)?Positive Airway Pressure)?

High-flow, pressurized & concentrated O2 delivery system

Exhalation port flow restriction device provides positive end expiratory pressure (PEEP) at a set level throughout inspiration & expiration preventing upper airway structures from collapsing &“splinting” open alveoli

By placing airway under a constant level of pressure throughout the respiratory cycle, obstructions are "pushed" out of the alveoli Increased intrathoracic pressure reduces preload & afterload, improving left

ventricular function Maintains patency of small airways & alveoli Improves gas exchange & reduces work of breathing by moving fluid into

vasculature Improves bronchodilator delivery

Noninvasive option to support pts through a respiratory crisis, avoid ETI, or buy time until ETI can be performed in a more controlled environment

CPAP vs BiPAPCPAP vs BiPAP

CPAP “Continuous” constant positive pressure throughout respiratory cycle

BiPAP “Bilevels” (2) of positive pressure during different phases of the

respiratory cycle When pt breathing in, Inspiratory Positive Airway Pressure (IPAP) exerted When pt breathing out, Expiratory Positive Airway Pressure (EPAP)

exerted

“Effects of BiPAP in patients with COPD” (European Respiratory Journal; 2000 )

BiPAP causes higher intrathoracic pressures & reduces myocardial perfusion

BiPAP causes lower tidal volumes & increases work of breathing (vs CPAP)

CPAP O2 DeliveryCPAP O2 Delivery

Prehospital CPAP devices powered by an O2 source that can deliver 50 psi

Some generators have a fixed flow rate, while others can be adjusted Fixed rates are either 35% or 100% but actual O2 concentration will be less depending

on leaks and minute ventilation Variable rate increases chance of inadequate oxygen supply

The percentage of oxygen delivered (FiO2) usually starts at 30% & can be increased depending on pt needs

At 28-30% FiO2 , a full tank should last approximately: D cylinder = 28 minutes E cylinder = 40-50 minutes M cylinder = 4 hours

Branson R, Davis K, Johannigman J. Comparison of Branson R, Davis K, Johannigman J. Comparison of continuous flow & a demand CPAP system for use in continuous flow & a demand CPAP system for use in

emergency care of CHF. emergency care of CHF. Prehosp Emerg Care. 2001 Apr-Jun;5(2):190-6.

The low flow Whisperflow device had a lower gas consumption than the fixed Whisperflow. E-cylinder operation duration was highest with the Whisperflow fixed compared to other devices

Whisperflow Low Flow FIO2 30% Gas Consumption 10 L/ min Gas Consumption with 5L/min Leak 10 L/ min Duration of Operation 60 mins

Whisperflow Fixed FIO2 30% Gas Consumption 15 L / min Gas Consumption with 5L/min Leak 15 L/ min Duration of Operation 30 mins

IndicationsIndications

Increased work of breathing & inability to effectively remove CO2

Poor respiratory effort & decreased air movement results in CO2 levels rising, causing a narcotic like effect on the brain (“CO2 Narcosis”)

Combined effects of fatigue & rising blood levels of CO2 lead to further lowering of the ventilation rate & respiratory failure

ContraindicationsContraindications

Need for emergent ETI

Hypotension

Cannot follow commands

Aspiration risk

Upper GI bleed / persistent vomiting

Recent facial trauma / surgery

Tracheostomy

Chest trauma / suspected pneumothorax

Claustrophobic (make an attempt)

Side EffectsSide Effects

Anxiety (most common)

As CPAP increases intra-thoracic pressure & gastric distention, there is a risk of hypotension & PTX

Abruptly stopping treatment can result in acute decompensation & need for ETI

Give hospital advance notice, so they can prepare

COPDCOPD

Lungs lose elastic recoil from scarred alveoli & bronchioles scar

Hypercarbic (ventilation issue)

Traditional therapies involve brochodilators (requires adequate ventilation)

Difficult to ETI prehospitally without RSI

Bronchioles collapse during exhalation leading to alveolar air trapping “Pursed lip” breathing increases “auto-PEEP”

COPD patients requiring ETI have worse outcomes than if managed conservatively Higher mortality & difficult to wean off ventilator rate if ETI

Aultman Study: COPDAultman Study: COPD

55 pts in CPAP group 3 intubations

43 pts in no CPAP group 15 intubations

30% reduction in ETI

5%

35%

0%

5%

10%

15%

20%

25%

30%

35%

CPAP CONTROL

Congestive Heart FailureCongestive Heart Failure

Incidence 1:100 pt transports > age 65 yo 25% medicare admissions Average LOS 6.7 days (longer if ETI) = 6.5 million hospital days annually

Increased interstitial fluid interferes with gas exchange / oxygenation Lymphatics remove 10-20cc pulmonary fluid/ hr When capability exceeded, fluid accumulates in alveolar air spaces, “drowning” pt

Increased myocardial workload resulting in higher O2 demands in pts who often have concominant ischemic heart disease

Traditional therapies designed to reduce pre-load & after-load as well as remove interstitial fluid

CPAP “pushes” fluid out of alveoli back into the vascular & lymphatic tissues 33% have ETI if no attempts at non-invasive pressure support Intubated pts have 4 X greater mortality of non-intubated pt

Aultman Study: CHF PatientsAultman Study: CHF Patients

51 pts in CPAP group 1 Intubation

82 pts in no CPAP group 22 Intubations

25% reduction in ETI

2%

27%

0%

5%

10%

15%

20%

25%

30%

CPAP CONTROL

AsthmaAsthma

Bronchospasm & increased work of breathing

Pts cannot physically move air in & out of the lungs due to spasm

CPAP delivers aerosolized medications & “splints” open spasming alveoli & bronchioles

Aultman Study: AsthmaAultman Study: Asthma

19 pts in CPAP group 3 intubations

7 pts in no CPAP group 2 intubations

12% reduction in ETI

16%

28%

0%

5%

10%

15%

20%

25%

30%

CPAP CONTROL

EquipmentEquipment

Easy to use & portable

Adjustable to patient’s needs

Easily started & discontinued

Provide quantifiable & reliable airway pressures

Conservative oxygen utilization

Limited interference with administration of “traditional” cardio-respiratory therapies

Necessary ComponentsNecessary Components

Oxygen source capable of producing 50 psi

Tight fitting mask

Flow regulator 30% fixed O2 concentration When attached to an O2 cylinder,

the primary regulator delivers 50 psi & device "sucks" in room air to dilute the 100% O2

PEEP ValvePEEP Valve

PEEP valve connected to exhalation port to maintain a constant circuit pressure

Each PEEP valve rated at a certain level measured in 2.5 cmH2O increments

Common increments are 5.0 or 7.5 cmH20

Important PointsImportant Points

Continually check for air leaks & pt tolerance

Do not break seal to administer medications

Even if status improves, continue CPAP until transferred to ED & personnel transfer pt to their equipment

If status deteriorates, discontinue CPAP & prepare for ETI

Notify destination hospital that CPAP is been used

CPAPCPAP ETIETI

Non-invasive Easily discontinued Easily adjusted BLS skill* Minimal complications Does not require sedation Minimal infection risk Comfortable and

physiologic

Invasive Requires mechanical

ventilation ALS skill Significant complications Requires sedation or RSI Potential for infection Uncomfortable and non-

physiologic

CPAP vs. IntubationCPAP vs. Intubation

*Not according to MA OEMS, unfortunately

Prehospital CPAP ResearchPrehospital CPAP Research

Provides greatest benefit when initiated early

Decreases intubations & improvement in respiratory symptoms with no major complications

In Helsinki CPAP used for >12 yrs on mobile ICUs for respiratory distress Improved oxygenation, lowered respiratory rate, HR & SBP Patients who were initially misdiagnosed as having CHF (i.e. pneumonia or

effusion) had no adverse side effects from CPAP

Prehospital Use of CPAP for Acute Severe CHF Prehospital Use of CPAP for Acute Severe CHF (JEMS. 2011)

OBJECTIVE: To describe the prehospital use of CPAP for patients presenting with acute severe HF in

urban NJ

METHODS: Retrospective review of pts treated for acute CHF Inclusion criteria: were: RR >25 bpm, respiratory distress, history of CHF, intact mental

status Data collected: demographics, vitals, need for ETI, complications

RESULTS (STATISTICALLY SIGNIFICANT): 387 pts met inclusion criteria, 149 had CPAP placement (39%) Prehospital treatment times :CPAP 30 min; non-CPAP 31 min Increase in O2 sat: CPAP 9%; non-CPAP 5% SBP reduction: CPAP 27 mmHg; non-CPAP 19.9 mmHg HR reduction: CPAP 17 bpm; non-CPAP 9 bpm RR reduction: CPAP 6 bpm; non-CPAP 4 bpm ETI reduction: CPAP 2%; non-CPAP 6%

CONCLUSION: CPAP for eligible patients with acute severe CHF feasible & beneficial

Evaluation of the effect of prehospital application of CPAP Evaluation of the effect of prehospital application of CPAP therapy in acute respiratory distress. therapy in acute respiratory distress. ((Prehospital Disaster Med. 2010)

OBJECTIVE: Test impact of CPAP on rural prehospital pts with acute respiratory distress

METHODS: 8 month, crossover, observational, non-blinded study

RESULTS: During the 4 months of baseline data collection, 8% pts with respiratory

distress were ETI within 1st 48 hours of care with an average ICU LOS of 8 days During the four months when CPAP available in the prehospital setting, ETI not

required for any patients in the field or in the ED, with 2 ICU admissions (average LOS 4 days)

CONCLUSIONS: The use of the CPAP in the prehospital setting is beneficial in acute respiratory

distress

Current Prehospital CPAP ResearchCurrent Prehospital CPAP Research

“Noninvasive Ventilation in Acute Cardiogenic Edema” JAMA, 2005 Meta-analysis of 22 studies with “good to excellent data” showed a 45% reduction in

mortality and a 60% reduction in ETI

Warner. “Evaluation of the effect of prehospital application of CPAP therapy in acute respiratory distress”. Prehosp Disaster Med. 2010 The use of prehospital CPAP is beneficial for pts in acute respiratory distress

Sullivan. “Prehospital use of CPAP: Positive pressure = positive patient outcomes”. Emerg Med Serv, 2005 CPAP alleviates symptoms & decreases need for ETI for pts with CHF, COPD &

asthma. CPAP does not replace ETI, rather is a less-invasive means of providing respiratory support while medications work to correct underlying causes of distress

Bledsoe. Low-fractional oxygen concentration continuous positive airway pressure is effective in the prehospital setting. PEC, 2012 CPAP using a low FiO2 (28%-30%) was highly effective in the treatment of commonly

encountered prehospital respiratory emergencies

Hubble. “Estimates of cost-effectiveness of prehospital Hubble. “Estimates of cost-effectiveness of prehospital CPAP in the management of acute pulmonary edema” CPAP in the management of acute pulmonary edema” PEC.

2008

METHODS A cost-effectiveness model of implementing CPAP in an urban EMS system was derived from

the societal and implementing EMS systems’ perspectives

RESULTS Cost of consumables, equipment & training = $89 per CPAP pt An EMS system would be expected to use CPAP 4:1000 EMS pts & expected to

save 0.75 lives:1000 EMS pts at a cost of $490 per life saved CPAP results in one less intubation per 6 CPAP applications to reduce

hospitalization costs by $4075 per year per CPAP application

CONCLUSION Aside from the ultiple studies have demonstrated the effectiveness of CPAP in

the management of acute pulmonary edema, prehospital CPAP also appears to be a cost-effective treatment for these patients

Aultman Study: SummaryAultman Study: Summary

Diagnosis ETI % No ETI

% ETI % No ETI %

CHF 1 50 22 60

Asthma 3 16 2 5

COPD 3 52 15 28

Pneumonia

0 3 2 6

Pulmonary Edema

4 11 6 1

Other 2 3 9 5

Total 13 9% 135 91% 56 35% 105 65%

CPAP Group (n = 148) Control Group (n = 161)

Key Point: 91% of all comers in the CPAP Group did not require prehospital ETI; 65% in the Control Group did require ETI to equal a 26% reduction 26% reduction in prehospital ETI

Wisconsin EMT–Basic StudyWisconsin EMT–Basic Study

Can EMT-Bs apply CPAP as safely as EMT-Ps? 50 EMT-Basic services 2 hour didactic, 2 hour lab, written & practical test

Because EMT–Basics don’t diagnose a unique “Respiratory Distress” protocol used to capture patients

Required data collection Criteria used to apply CPAP Absence of contraindications Q 5 min. vitals Subjective dyspnea score

Wisconsin EMT–Basic Study Wisconsin EMT–Basic Study ResultsResults

500 applications of CPAP in 114 services 99% met criteria for appropriate CPAP application

No field intubations required by ALS intercepts and no significant complications

All O2 sats improved, dyspnea scores reduced by 50%

Results replicated in 20+ studies since, demonstrating that pts receiving prehospital CPAP have a significantly lower incidence of ETI compared to conventional “respiratory distress” therapy

Pts not receiving prehospital CPAP 6 x more likely to require ETI (Marchetta et al)

CPAP group 355 days less LOS If CPAP + intubation patients still had 6 days fewer LOS ICU Admission reduced 62%

Points to ConsiderPoints to Consider

How good is your current therapy for respiratory distress? Aggressive nitrates for CHF? Aggressive use of bronchodilators? Prehospital & ED intubation rate?

Do you have active medical oversight? Advanced airway management is considered a sentinel event

ALS or BLS or BOTH?

OEMS 3.4 Bronchospasm / Respiratory Distress OEMS 3.4 Bronchospasm / Respiratory Distress Assessment & Treatment PrioritiesAssessment & Treatment Priorities

Scene safety, BSI

Maintain open airway, assist ventilations prn, administer oxygen as needed

Check hemodynamic stability, symptoms, LOC, ABCs, vitals, monitor / ECG

Obtain OPQRST & SAMPLE

Determine level of respiratory distress Mild: Slight wheezing. mild cough, able to move air without difficulty Severe: Poor air movement, dyspnea, use of accessory muscles, tachypnea,

tachycardia. May present without wheezes

Rapid transport w/ wo ALS. Do not allow pt to exert themselves in a position of comfort or appropriate to treatment(s) required

OEMS 3.4 Bronchospasm / Respiratory Distress OEMS 3.4 Bronchospasm / Respiratory Distress BLS ProceduresBLS Procedures

Activate ALS intercept but initiate rapid transport w / wo ALS

Mild Distress: Encourage &/or assist pt to self-administer their prescribed inhaler if

indicated Continually reassess vitals Contact Medical Control to:

Repeat a 2nd MDI dose if required & if maximum dose not reached Assist in using MDI Use MDI if not specifically been prescribed for patient

OEMS 3.4 Bronchospasm / Respiratory OEMS 3.4 Bronchospasm / Respiratory Distress ALS ProceduresDistress ALS Procedures

Mild Distress: Albuterol 2.5-3 mg neb, with additional treatments prn

Severe Distress: Advanced airway management prn with capnography Albuterol 2.5-3 mg neb or MDI +/- Ipratropium 500 mcg Additional neb treatments administered prn w / wo magnesium 2 gms IV IV NS KVO; if SBP <100 mmHg administer 250 cc bolus or titrate to HD status Administer CPAP if not contraindicated; nebulizer therapy can be continued with CPAP

Contact Medical Control to/for: Repeated albuterol or ipratropium neb or MDI Epinephrine 0.15-0.3 mg IM (may q15 min.) or 1:10,000 (NOT 1:1000), 0.1 mg- 0. 5 mg

slow IVP Magnesium Sulfate 2-4 gms IV over 5 mins

CAUTION Use of epinephrine in pts >40 yo or with known cardiac disease or in pts who have

already taken high dosage of inhalant bronchodilator medications may result in cardiac complications

OEMS 3.5 CHF / Pulmonary Edema OEMS 3.5 CHF / Pulmonary Edema Treatment / Assessment PrioritiesTreatment / Assessment Priorities

Scene safety & BSI

Maintain open airway, assist ventilations & administer O2 prn

Place pt in position of comfort

Determine hemodynamic stability, symptoms, LOC, ABCs, vitals, +/- monitor & ECG

OPQRST & SAMPLE history

Rapid transport w / wo ALS, do not allow pt to exert themselves & place in position of comfort

OEMS 3.5 CHF / Pulmonary Edema BLS OEMS 3.5 CHF / Pulmonary Edema BLS ProceduresProcedures

Activate ALS intercept if necessary & available

Rapid transport, w / wo ALS

Notify receiving hospital

OEMS 3.5 CHF / Pulmonary Edema ALS OEMS 3.5 CHF / Pulmonary Edema ALS ProceduresProcedures

Advanced airway management w/ capnography if indicated

IV NS KVO en route to the hospital

If SBP < 100 mmHg administer 250 cc bolus or titrate to HD status

NTG SL or spray if SBP > 100 mmHg; may repeat q5 mins x 2 If pt has taken a PDE5- inhibitor (i.e. Viagra) do not administered without a medical

control order Contact Medical Control if SBP <100 mmHg

Contact Medical Control for / if: Nitropaste 1 inch to anterior chest wall Furosemide 20-40 mg IVP or 40-80mg IVP if patient already on diuretics Dopamine 2 - 20 mcg/kg/min To facilitate ETI Medical Control may order Midazolam 2.5 mg IN or slow IVP. Repeat

prn to a total dose of 5 mg

SummarySummary

CPAP alleviates respiratory symptoms & decreases need for intubation for patients with respiratory distress

Safe, portable & easy to apply

Does not replace ETI, but is a less-invasive means of providing respiratory support while medications work to correct the underlying cause of respiratory distress

Better results with rapid & aggressive utilization for the majority of patients with respiratory distress

The earlier CPAP placed, the better the outcomes

Use your medical control!

ReferencesReferences

Keith Wesley MD. Wisconsin State EMS Medical Director

Mark Marchetta RN, BS, NREMT-P; Mark Resanovich, EMT-P. Aultman Health Foundation (Canton, Ohio)

OEMS website and MA State Prehospital Treatment Protocol

Brady & Mosby Textbooks “Respiratory Distress”

Also see references cited throughout presentation