Presentation on theme: "Pre-Hospital CPAP What EMS should know"— Presentation transcript:
1Pre-Hospital CPAP What EMS should know Joe Holley, MD FACEPEMS Medical Director, State of TennesseeMember, ACEP EMS Committee
2Objectives Review the goal & physiology of CPAP Discuss the indications and contraindications for CPAP useReview the literature supporting CPAP useExplore the role of CPAP use by pre-hospital providersDiscuss the methods for implementing pre-hospital CPAP
3PREHOSPITAL EMERGENCY CARE 2011;15:418 NIPPV is an important prehospital treatment modality for acute dyspnea.EMS agencies should select NIPPV systems and developdyspnea care protocols suited to their patientpopulations, clinical capabilities, and receivingemergency department뭩 resources.EMS agencies must conduct quality assurance andinspection efforts to verify the safety and effectivenessof NIPPV.PREHOSPITAL EMERGENCY CARE 2011;15:418
4Reduce the need for pre-hospital intubation! The Goal of CPAP?Reduce the need for pre-hospital intubation!
5CPAP vs. Intubation CPAP Non-invasive Easily discontinued Easily adjustedUse by EMT-BMinimal complicationsDoes not require sedationComfortableIntubationInvasiveIntubated stays intubatedRequires highly trained personnelSignificant complicationsCan require sedation or RSIPotential for infectionIntensive Resource UtilizationImpact on the System
6The Problem Congestive Heart Failure Incidence 10 per 1000 patient (over age 65) transports25% of Medicare AdmissionsAverage LOS is 6.7 days6.5 million hospital daysThose who get intubated have significantly longer LOS33% get intubated without non-invasive pressure supportIntubated patients have 4 times the mortality of non-intubated patients
7The 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
8The Problem COPD/Asthma Increased work of breathing Hypercarbic (ventilation issue)Traditional therapies involve brochodilators which require adequate ventilationHigher mortality rate if intubatedDifficult to wean once intubatedExtremely difficult patient to intubate in the pre-hospital arena – usually requires RSI
9Physiology of CPAPAirway pressure maintained at set level throughout inspiration and expirationMaintains patency of small airways and alveoliImproves gas exchangeImproves delivery of bronchodilatorsMoves extracellular fluid into vasculatureReduces work of breathing
10Supporting Literature JAMA December 28, 2005 “Noninvasive Ventilation in Acute Cardiogenic Edema”, Massip et. al.Meta-analysis of studies with good to excellent data45% reduction in mortality60% reduction in need to intubate
11EFFECTIVENESS 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;10:430–43995 patients received standard therapy, and 120 patients received CPAP and standard therapy for Pulmonary EdemaIntubation 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 groupWhen compared with the control group, the CPAP group had more improvementPatients receiving standard treatment were more likely to be intubated and more likely to die than those receiving standard therapy and CPAP.
12Supporting 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.”
13Supporting Literature Brochard (French abstract) “ Noninvasive ventilation for acute exacerbations of COPD”“…can reduce the need for intubation, LOS in hospital, and mortality rate”
14Pre-hospital CPAPPEC 2000 NAEMSP Abstract, “Pre-hospital use of CPAP for presumed pulmonary edema: a preliminary case series”, Kosowsky, et. al.19 patientsMean duration of therapy minutesOxygen sat. rose from 83.3% to 95.4%None were intubated in the field2 intubated in the ED5 subsequently intubated in hospital“Pre-hospital CPAP is feasible and may avert the need for intubation”
15Types 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.
16Is 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.
17Is 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
18Delivery System Types External Pressure Regulated Turbulent Flow Virtual Valve
19External 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.
20DisadvantagesA 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.
21Turbulent 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.
22DisadvantagesA 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.
23Transport 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.
24Indications for CPAPThe general indication for NIPPV is dyspnea accompanied by early respiratory failure in patients with intact protective airway reﬂexes and mental status.CHFPulmonary EdemaNear DrowningInhalation ExposureCOPDAsthmaPneumonia
25Possible IndicationsWhile utilized in in-hospital practice, the role of NIPPV for pneumonia-associated respiratory failure is less clear.
26ContraIndicationsPatients 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 NIPPVincreased risks of vomiting and aspirationconsider ETI for these patients.
27Use 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
28Generally Accepted ContraIndications Patient less than eight years of age (Fitment Issues)Unable to maintain a patent airwayDecreased level of consciousness (LOC)PneumothoraxFacial trauma/burnsSystolic BP < 90 mmHgRecent surgery to face or mouthEpistaxisPatient unable to tolerate mask or pressurePneumonia (relative contraindication)
29What 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.
30IntubationPatients 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.
31Training Key elements of training should cover: Pathophysiology of acute dyspneaPhysiology of NIPPV systemsDescription of CPAP and BiPAP mechanics, with focus on the systems available to the individual EMS agencyIndications and contraindications for NIPPVInitiation and titration of NIPPV therapyTitration of concurrent pharmacologic therapyManagement of adverse eventsTransition of care at the receiving hospitalAlternate care strategies
32TrainingThe 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
33Application 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.
34Medication 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
35Patient MonitoringRespiratory 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.
36Wisconsin EMT–Basic Experience Question: Can EMT-Basics apply CPAP as safely as Paramedics?50 EMT-Basic services2 hour didactic, 2 hour lab, written and practical testRequired data collectionCompared to same data collected by ALS services during same period
37Wisconsin EMT–Basic Experience Required data collectionCriteria used to apply CPAPAbsence of contraindicationsQ 5 min. vital signs including oxygen sats.Subjective dyspnea scoreBecause EMT–Basics don’t diagnose a unique “Respiratory Distress” protocol used to capture patients
38Adult Respiratory Distress Protocol (Age greater than 12)Routine Medical AssessmentOxygen2 LPM via Nasal CannulaTitrate to maintain Pulse ox of >92%Is Patient a candidate for Mask CPAP?Respiratory Rate > 25 / minRetractions or accessory muscle usePulse ox < 94% at any timeYesSee Mask CPAP ProtocolNoIs the Patient wheezing and/or doesthe Patient have a history of Asthma/COPD?YesAdminister Albuterol /Atrovent by NebulizerStep through the protocol.Emphasize the need for medical care regardless of whether or not the patient is a CPAP candidateNoDoes the Patient have rales and/or does thePatient have a history of congestive heartfailure (CHF)?If Basic IV Tech:Administer 1 spraysublingual NTG every5 minutes as long assystolic BP is greater than100mmHgYesNoContact Medical ControlConsider ALS Intercept and Transport
39Mask CPAP for EMT-Basic Asses Patient, record vital signsand pulse ox before applying oxygenCPAP Inclusion Criteria(2 or more of the following)Retractions or Accessory muscle useRespiratory Rate > 25 / minutesPulse Ox < 94% at any timeCPAP Exclusion Criteria-Unable to follow commandsApneaVomiting or active GI bleedMajor trauma / pneumothoraxConditions Indicated for CPAPCongestive Heart FailureCOPD / AsthmaPneumoniaDoes the Patient meet two or moreInclusion Criteria?NoYesYesDoes the Patient meet anyExclusion Criteria?Continue standard BLSRespiratory Distress ProtocolNoAdminister CPAP5 cm H2O of pressure ANDReassess patient, vital signs, andrespiratory distress scale every 5 min.Step through the CPAP protocolStress the need for frequent vital signs and patient assessmentPatient condition is deterioratingDecreasing LOCDecreasing Pulse OxNotify Medical ControlConsider ALS Interceptand continue BLSRespiratory Distress ProtocolPatient condition is stableor improvingNotify Medical ControlContinue CPAPReassess patient every5 minutesRemove CPAPApply BVM Ventilation
40Wisconsin EMT-Basic Experience Results (preliminary – study completed 11/05)500 applications of CPAP (114 services)99% met criteria for CPAP on review of medical directorNo field intubations by those services with ALS interceptsNo significant complicationsAll oxygen sats. improved, dyspnea reduced by average of 50%
41Wisconsin EMT – Basic Experience State approved CPAP for EMT-Basic scope of practice 2/06Questions yet to be answeredWhat conditions did the patients have?Was it applied too liberally?Key PointServices without ALS intercept did just as well as those with it
42Implementation 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 oversightAirway management is a sentinel eventALS or BLS or BOTH?
43Items to Consider Equipment Must be easy to use and portable Adjustable to patient’s needEasily started and discontinuedProvide quantifiable and reliable airway pressuresConservative oxygen utilizationNot interfere with administration traditional therapies for underlying condition
44Items 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 ventilationVariable rate increases chance of inadequate oxygen supplyPressure levelMost studies show 5cm H20 sufficientComplication rate goes up with pressure
45SummaryCPAP is a non-invasive procedure that is easily applied and can be easily discontinued without untoward patient discomfortCPAP is an established therapeutic modalityData supports its use in CHF, pulmonary edema, COPD/Asthma, and pneumonia
46The Future NAEMSP is a strong supporter of CPAP in the field The Data is very solid supporting its useSafetyCost effectivenessIts SIMPLY the RIGHT THING for OUR Patients!!
47What’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 adoptEfficiencies Improve if adopted on a system wide basis