1. Pre-Hospital CPAP What EMS should know
Joe Holley, MD FACEP
EMS Medical Director, State of Tennessee
Member, ACEP EMS Committee

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. PREHOSPITAL EMERGENCY CARE 2011;15:418
NIPPV is an important prehospital treatment modality for acute dyspnea.
EMS agencies should select NIPPV systems and develop
dyspnea care protocols suited to their patient
populations, clinical capabilities, and receiving
emergency department뭩 resources.
EMS agencies must conduct quality assurance and
inspection efforts to verify the safety and effectiveness
of NIPPV.
PREHOSPITAL EMERGENCY CARE 2011;15:418

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

5. CPAP vs. Intubation CPAP Non-invasive Easily discontinued
Easily adjusted
Use by EMT-B
Minimal complications
Does not require sedation
Comfortable
Intubation
Invasive
Intubated stays intubated
Requires highly trained personnel
Significant complications
Can require sedation or RSI
Potential for infection
Intensive Resource Utilization
Impact on the System

6. 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

7. 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

8. 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

9. 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

10. 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

11. EFFECTIVENESS OF PREHOSPITAL CONTINUOUS POSITIVE AIRWAY PRESSURE IN THE MANAGEMENT OF ACUTE PULMONARY EDEMA Michael W. Hubble, PhD, NREMT-P, Michael E. Richards, MD, MPA, Roger Jarvis, EMT-P, Tori Millikan, EMT-P, Dwayne Young, BS, EMT-P PREHOSPITAL EMERGENCY CARE 2006;10:430–439
95 patients received standard therapy, and 120 patients received CPAP and standard therapy for Pulmonary Edema
Intubation was required in 8.9% of CPAP-treated patients compared with 25.3% in the control group (p = 0.003), and mortality was lower in the CPAP group than in the control group
When compared with the control group, the CPAP group had more improvement
Patients receiving standard treatment were more likely to be intubated and more likely to die than those receiving standard therapy and CPAP.

12. Supporting Literature
Reviews in Cardiovascular Medicine, vol. 3 supl , “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.”

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

14. 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 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”

15. Types of Positive Pressure Ventilation
1) continuous positive airway pressure (CPAP)
applies uniform supportive pressure during both inspiratory and expiratory phases.
2) bilevel positive airway pressure (BiPAP) is similar to CPAP but alternates different levels of inspiratory and expiratory pressure.
Both CPAP and BiPAP systems typically provide pressure support of 4-10 cmH2O.

16. Is it Cost Effective?
Hubble et al. evaluated the cost-effectiveness of prehospital CPAP in acute pulmonary edema.
Using data from their 2006 publication, they predicted that four of every 1,000 EMS patients would require CPAP for acute pulmonary edema, resulting in 0.75 lives saved.

17. Is it Cost Effective?
Accounting for the cost of CPAP equipment, including the cost of the CPAP-generating system, disposable mask, and tubing for each patient, training of personnel, and oxygen usage, the authors estimated that the cost-benefit of prehospital CPAP was $490 per life saved.
They also predicted that CPAP would reduce hospitalization costs by $4,075 per year per application.
Didn’t include the value of avoiding the ICU, Mechanical Ventilation, Complications, or availability of ICU bed for “the Next Patient”….potentially worth thousands of dollars

18. Delivery System Types External Pressure Regulated
Turbulent Flow Virtual Valve

19. External Pressure Regulated
Regulator-based portable NIPPV systems generate continuous pressure from oxygen flow, directly controlling inspiratory and expiratory pressure.
Regulator-based NIPPV systems allow different inhaled oxygen fractions, reducing oxygen consumption.
At 10 cmH2O pressure and 100% inspired oxygen (flowrate of 15 L/min), a size D oxygen cylinder will last between 20 and 30 minutes.
At 65% inspired oxygen, a size D oxygen cylinder may last approximately 35 minutes.
Regulator-based systems are often compatible with end-tidal capnometry and in-line medication nebulizers.

20. Disadvantages
A disadvantage of regulator-based systems is their size; portable NIPPV regulators weigh approximately 3 pounds.
Regulator-based systems are also expensive; the regulator costs $1,000-1,500, and each disposable hose circuit costs $25-50.
Portable NIPPV systems may not be compatible with hospital wall oxygen outlets.
During transition of care to the ED, EMS personnel may need to rely on portable oxygen tanks to maintain NIPPV operation until the availability of hospital NIPPV equipment.

21. Turbulent Flow Virtual valve.
The Boussignac CPAP system uses a different NIPPV approach, accelerating oxygen flow through a series of channels to create turbulence.
The turbulence acts as a virtual valve, generating positive airway pressure.
The system is lightweight and disposable (single use) and uses a conventional oxygen source and flow regulator.
Each disposable circuit costs approximately $70.
On arrival at the ED, EMS personnel may transfer the system to hospital wall oxygen, thus minimizing care transfer delays.

22. Disadvantages
A disadvantage of the Boussignac system is its limited maximum positive pressure of ~10 cmH2O with an oxygen flow of 25 L/min.
Consequently, the system requires large quantities of oxygen.
For a CPAP pressure of 5.0 cmH2O, a size D oxygen cylinder will last approximately 23 minutes.
To generate a CPAP pressure of 10 cmH2O, a size D cylinder will last 14 minutes.

23. Transport Ventilators
Select transport ventilators may be designed to provide BiPAP or CPAP.
While dependent on the individual brand and model, the process involves placing the ventilator in pressure support mode, setting a desired inspiratory pressure support value, and setting a desired positive end-expiratory pressure (PEEP) value.

24. Indications for CPAP
The general indication for NIPPV is dyspnea accompanied by early respiratory failure in patients with intact protective airway reflexes and mental status.
CHF
Pulmonary Edema
Near Drowning
Inhalation Exposure
COPD
Asthma
Pneumonia

25. Possible Indications
While utilized in in-hospital practice, the role of NIPPV for pneumonia-associated respiratory failure is less clear.

26. ContraIndications
Patients with severe respiratory distress may not tolerate NIPPV.
not suitable for patients with an absence of a gag reflex or altered mental status.
not be able to cooperate with NIPPV
increased risks of vomiting and aspiration
consider ETI for these patients.

27. Use In Trauma? The utility in major trauma is unclear
Invasive airway management of major trauma is difficult, and NIPPV may provide transient ventilatory support in these patients.
However, potential NIPPV pitfalls in the setting of trauma include the risk of pneumocephalus, subcutaneous emphysema or bacterial meningitis in patients with midface fractures, pneumothorax in thoracic trauma, and increased intrathoracic pressure causing hypotension

28. Generally Accepted ContraIndications
Patient less than eight years of age (Fitment Issues)
Unable to maintain a patent airway
Decreased level of consciousness (LOC)
Pneumothorax
Facial trauma/burns
Systolic BP < 90 mmHg
Recent surgery to face or mouth
Epistaxis
Patient unable to tolerate mask or pressure
Pneumonia (relative contraindication)

29. What about the Hypoxic Drive Issue?
Certainly this physiologic phenomenon exists, it is relatively uncommon and many hypoxic COPD patients have been denied much needed oxygen out of fear of causing worse hypercapnia. As a result, left ventricular function suffers as does renal, mental and other related issues.
Moreover, when this phenomenon does occur, it is in the setting of non-pressurized oxygen delivery (read nasal cannula or face masks) and not with CPAP, BiPAP or intubation and placement of the patient on mechanical artificial ventilation. All three of these modalities resolve hypercapnia by increasing alveolar ventilation. Recall that as alveolar ventilation goes up, PaCO2 goes down and respiratory acidosis lessens.
The COPD patient with known hypercapnia should never be transported to the ED on non-pressurized oxygen. However, hypoxic COPD patients can be safely transported with supplemental oxygen driven by CPAP.

30. Intubation
Patients who cannot cooperate, maintain their own airway, or have adequate respiratory effort are not candidates for CPAP. They require immediate intubation.
Monitor your patient for a failure to respond to CPAP, as noted by a declining mental status or ability to comply with CPAP. Not all patients will respond, and may require intubation.
Patients who have intractable vomiting may not be able to protect their airway, and need intubation.

31. Training Key elements of training should cover:
Pathophysiology of acute dyspnea
Physiology of NIPPV systems
Description of CPAP and BiPAP mechanics, with focus on the systems available to the individual EMS agency
Indications and contraindications for NIPPV
Initiation and titration of NIPPV therapy
Titration of concurrent pharmacologic therapy
Management of adverse events
Transition of care at the receiving hospital
Alternate care strategies

32. Training
The technique of NIPPV application will vary with the employed system.
Application of the face mask must ensure a tight seal.
Facial hair may require trimming to achieve a tight seal.
An adequate mask seal may not be possible with edentulous patients or individuals with facial abnormalities.
Patient Coaching is very important to successful application

33. Application in the Field
Continuous positive airway pressure systems have single pressure setting for both inspiration and expiration. A typical initial setting is 5 cmH2O, with pressure adjustments every few minutes in response to the patient’s subjective and objective work of breathing, respiratory rate, and oxygen saturation.
The typical range of pressure settings is 5-10 cmH2O.
Bilevel positive airway pressure is similar to CPAP, but alternates a higher inspiratory pressure with a lower expiratory pressure.
Typical initial settings include an inspiratory pressure of 10 cmH2O and an expiratory pressure of 5 cmH2O, with subsequent adjustments according to patient response.

34. Medication Administration
Many CPAP devices allow for the concurrent administration of nebulized medications.
Medications are generally more effective due to improved recruitment, airway patency, and pressure support.
Indications for Bronchodilators are the same regardless of the use of CPAP

35. Patient Monitoring
Respiratory rate: A reduction in respiratory rate (and effort) may indicate clinical response to NIPPV.
Heart rate: Improvement in ventilation and perfusion with NIPPV may reduce the heart rate. However, the heart rate may also increase in response to increased intrathoracic pressure and decreased venous return.
Systolic blood pressure: The increase in intrathoracic pressure from NIPPV may decrease venous return to the heart, leading to a decrease in blood pressure. The development of hypotension (systolic blood pressure <100 mmHg) or hypoperfusion (cyanosis, decreased capillary refill) may indicate the need for reduced NIPPV support.
Oxygen saturation: Oxygen saturation may improve with application of NIPPV.
End-tidal capnography: End-tidal carbon dioxide (ETCO2) monitoring to gauge NIPPV response.
Upon initial application of NIPPV, ETCO2 may increase from improvement in ventilatio/perfusion mismatch. Decreasing ETCO2 may reflect respiratory improvement from NIPPV.
Subjective dyspnea ratings of patient subjective dyspnea, auscultation intensity, cyanosis, and accessory respiratory muscle use.

36. 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

37. 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

38. 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
Yes
See Mask CPAP Protocol No
Is the Patient wheezing and/or does
the Patient have a history of Asthma/COPD?
Yes
Administer Albuterol /
Atrovent by Nebulizer
Step through the protocol.
Emphasize the need for medical care regardless of whether or not the patient is a CPAP candidate No
Does the Patient have rales and/or does the
Patient have a history of congestive heart
failure (CHF)?
If Basic IV Tech:
Administer 1 spray
sublingual NTG every
5 minutes as long as
systolic BP is greater than
100mmHg
Yes No
Contact Medical Control
Consider ALS Intercept and Transport

39. Mask CPAP for EMT-Basic
Asses Patient, record vital signs
and pulse ox before applying oxygen
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
Does the Patient meet two or more
Inclusion Criteria? No
Yes
Yes
Does the Patient meet any
Exclusion Criteria?
Continue standard BLS
Respiratory Distress Protocol No
Administer CPAP
5 cm H2O of pressure AND
Reassess patient, vital signs, and
respiratory distress scale every 5 min.
Step through the CPAP protocol
Stress the need for frequent vital signs and patient assessment
Patient condition is deteriorating
Decreasing LOC
Decreasing Pulse Ox
Notify Medical Control
Consider ALS Intercept
and continue BLS
Respiratory Distress Protocol
Patient condition is stable
or improving
Notify Medical Control
Continue CPAP
Reassess patient every
5 minutes
Remove CPAP
Apply BVM Ventilation

40. 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%

41. 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

42. Implementation in Your System
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?

43. 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

44. 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

45. 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

46. The Future NAEMSP is a strong supporter of CPAP in the field
The Data is very solid supporting its use
Safety
Cost effectiveness
Its SIMPLY the RIGHT THING for OUR Patients!!

47. What’s the holdup?
Yet to be recognized by payors as a separate billable service.
Medicare currently will only pay if its used in conjunction with Endotracheal Intubation!!
What’s the Point!!!!
Hospitals have been slow to adopt
Efficiencies Improve if adopted on a system wide basis

48. Questions?
Joe Holley, MD FACEP