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Continuous Positive Airway Pressure (CPAP) Washington State Department of Health EMT Basic Curriculum Developed by: Lynn Wittwer, MD, MPD Marc Muhr, EMT-P.

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Presentation on theme: "Continuous Positive Airway Pressure (CPAP) Washington State Department of Health EMT Basic Curriculum Developed by: Lynn Wittwer, MD, MPD Marc Muhr, EMT-P."— Presentation transcript:

1 Continuous Positive Airway Pressure (CPAP) Washington State Department of Health EMT Basic Curriculum Developed by: Lynn Wittwer, MD, MPD Marc Muhr, EMT-P TJ Bishop, EMT-P Clark County EMS Keith Wesley, MD, EMS Medical Director State of Wisconsin

2 Washington EMT-B CPAP Curriculum2 CPAP Curriculum – EMT Basic Introduction Review of Anatomy and Physiology CPAP Overview Pulse Oximetry Review of Respiratory Distress Treatment With CPAP

3 Washington EMT-B CPAP Curriculum3 What is CPAP? Continuous Positive Airway Pressure (CPAP) A non-invasive alternative to intubation Does not require any sedation It provides comfort to the patient with acute respiratory distress by reducing work of breathing

4 Washington EMT-B CPAP Curriculum4 Why CPAP? Respiratory Distress is a common reason why people call 911! Established therapeutic alternative Easily applied, easily discontinued

5 Washington EMT-B CPAP Curriculum5 Key Points of CPAP CPAP has been successfully demonstrated as an effective adjunct in the management of a variety of respiratory distress states. CPAP may prove to be a viable alternative in many patients previously requiring endotracheal intubation by prehospital personnel.

6 Washington EMT-B CPAP Curriculum6 CPAP vs. Intubation CPAP –Non-invasive –Easily discontinued –Easily adjusted –Use by EMT-B –Does not require sedation –Comfortable Intubation –Invasive –Usually don’t extubate in field –Potential for infection –Requires highly trained personnel –Can require sedation –Traumatic

7 Review of Anatomy & Physiology

8 Washington EMT-B CPAP Curriculum8 Elements of the Airway UPPER AIRWAY NaresNasopharynxOropharynxTongueEpiglottis/Glottis Vocal Cords LOWER AIRWAY Trachea/EsophagusCarina Main stem Bronchi Secondary Bronchi BronchiolesAlveoli

9 Washington EMT-B CPAP Curriculum9 Upper Airway

10 Washington EMT-B CPAP Curriculum10 Pharynx Pharynx Nasopharynx –Uppermost portion of airway, just behind nasal cavities –Nasal septum –Vestibule –Olfactory membranes –Sinuses Oropharynx –Begins at the level of the uvula and extends down to the epiglottis –Opens into the oral cavity

11 Washington EMT-B CPAP Curriculum11 Larynx Three main functions: –Air passageway between the pharynx and lungs –Prevents solids and liquids from entering the respiratory tree –Involved in speech production

12 Washington EMT-B CPAP Curriculum12 Larynx An outer casing of nine cartilages –Thyroid cartilage –Cricoid cartilage Only complete cartilaginous ring in the larynx –Epiglottis Hyoid bone Cricothyroid membrane Vocal cords

13 Washington EMT-B CPAP Curriculum13 Lower Airway

14 Washington EMT-B CPAP Curriculum14

15 Washington EMT-B CPAP Curriculum15 Lungs Principal function is respiration Attached to heart by pulmonary arteries and veins Separated by mediastinum and its contents Base of each lung rests on the diaphragm Apex extends 2.5 cm above each clavicle

16 Washington EMT-B CPAP Curriculum16 Pleural Cavity A separate pleural cavity surrounds each lung Two layers (visceral and parietal) Pleural space

17 Washington EMT-B CPAP Curriculum17 Respiratory System - Physiology The respiratory system functions as a gas exchange system Oxygen is diffused into the bloodstream for use in cellular metabolism

18 Washington EMT-B CPAP Curriculum18 Respiratory System - Physiology Wastes, including carbon dioxide, are excreted from the body via the respiratory system

19 Washington EMT-B CPAP Curriculum19 Ventilation Ventilation refers to the process of air movement in and out of the lungs The volume of air moved in each breath is the tidal volume The volume still remaining in the chest after exhalation is the functional reserve capacity. FRC

20 Washington EMT-B CPAP Curriculum20 Inspiration and Expiration Inspiration –Chest wall expands –Lung space increases –Pressure gradient causes gas to flow into the lungs Expiration –Chest wall relaxes –Elastic recoil causes thorax and lung space to decrease in size –Pressure gradient created in thoracic cavity causes air to move out of the chest

21 Washington EMT-B CPAP Curriculum21 Pressure Changes During Inspiration and Expiration

22 Washington EMT-B CPAP Curriculum22 Mechanics of Breathing

23 Washington EMT-B CPAP Curriculum23 Mechanics of Respiration

24 Washington EMT-B CPAP Curriculum24 Ventilation The following must be intact for ventilation to occur: –Neurologic control to initiate ventilation –Nerves between the brainstem and the muscles of respiration –Functional diaphragm and intercostal muscles –A patent upper airway –A functional lower airway –Alveoli that are functional and not collapsed

25 Washington EMT-B CPAP Curriculum25 Diffusion In order for diffusion to occur, the following must be intact: –Alveolar and capillary walls that are not thickened –Interstitial space between the alveoli and capillary wall that is not enlarged or filled with fluid

26 Washington EMT-B CPAP Curriculum26 How does CPAP work Splints the upper airway preventing collapse Uses continuous oxygen flow with pressure to push air into the lungs and push the fluid into the bloodsteam Recruits alveoli that have collapsed

27 Washington EMT-B CPAP Curriculum27 CPAP Mechanism Increases pressure within airway. Airways at risk for collapse from excess fluid are stented open. Gas exchange is maintained Increased work of breathing is minimized

28 Washington EMT-B CPAP Curriculum28 Pulse Oximetry Basic concept of Pulse Oximetry monitoring. –Objectively determines oxygenation status when applied correctly. –Measures the hemoglobin saturation in the bloodstream via red and infrared light, through the skin to the arterial bed.

29 Washington EMT-B CPAP Curriculum29 Pulse Oximetry Possible invalid readings –Low blood flow states, (i.e., shock states, hypothermic, hypovolemia) may show an inaccurate low oxygenation percent. –Carbon monoxide poisoning may show a false high percent reading. –Anemias and oxygen capacity carrying diseases (i.e., sickle cell) may also show a false high reading. –Fingernail polish, excessive grease and dirt, nail-tips, or gel nails may cause a false low reading.

30 Review of Respiratory Distress

31 Washington EMT-B CPAP Curriculum31 Respiratory Distress Work of Breathing –Respiratory rate greater than 25/minute –The presence of retractions and/or use of accessory muscles Appearance = Mental Status –Pulse Oximetry < 94% –Effects of hypoxia and hypercarbia indistinguishable Circulation/Skin Color –Severe cyanosis –Pallor and diaphoresis

32 Washington EMT-B CPAP Curriculum32 Focused History and Physical Ascertain the patient’s chief complaint that may include: –Dyspnea –Chest pain –Cough ProductiveNon-productiveHemoptysis –Wheezing –Signs of infection Fever, chills Increased sputum production

33 Washington EMT-B CPAP Curriculum33 History Previous experiences with similar/identical symptoms Known pulmonary diagnosis Medication history –Current medications –Medication allergies –Pulmonary medications –Cardiac-related drugs History of the present episode Exposure and smoking history

34 Washington EMT-B CPAP Curriculum34 Pulmonary Edema – Congestive Heart Failure Defined –Fluid which collects in the lung tissue and alveoli Signs/Symptoms/Assessment –Anxious, Pale, Clammy, Dyspnea, Tachypnea, Confusion, Edema, Hypertension, Diaphoretic –Rales, Ronchi, Tachycardia, JVD, Pink Frothy Sputum, Cyanosis

35 Washington EMT-B CPAP Curriculum35 Pulmonary Edema – Congestive Heart Failure Signs/Symptoms/Assessment –Fatigue –Nocturia –Dyspnea on exertion –Paroxysmal nocturnal dyspnea –Chest Pain –Orthopnea

36 Washington EMT-B CPAP Curriculum36 Pulmonary Edema – Congestive Heart Failure Treatment –Focused history and physical exam –Complains of trouble breathing. Airway control w/ adequate ventilation Oxygenation –Has a prescribed nitroglycerine available. Consult medical direction. Facilitate administration of nitroglycerine –Baseline vital signs. –Reassess

37 Washington EMT-B CPAP Curriculum37 Chronic Obstructive Pulmonary Disease (COPD) Defined –Lung tissue loses elasticity secondary to destruction of the alveoli (Emphysema) –Inflammation of the bronchial tree. Diagnosed by productive cough which lasts at least three months a year for at least two consecutive years (Chronic Bronchitis) –Any COPD patient may have both

38 Washington EMT-B CPAP Curriculum38 Chronic Obstructive Pulmonary Disease (COPD) Signs/Symptoms/Assessment –Exertional dyspnea –Productive cough/wheezing –Minor hemoptysis –Tachypnea/exertional muscle use –Pursed lip exhalation –May have coarse crackles –Accessory muscle use –Hyperexpansion of the thorax (diminished breath sounds) –Excessive caloric expenditure

39 Washington EMT-B CPAP Curriculum39 Chronic Obstructive Pulmonary Disease (COPD) Signs/Symptoms/Assessment –Tachypnea, cyanosis, agitation, tachycardia, hypertension –Confusion, tremor, stupor, apnea

40 Washington EMT-B CPAP Curriculum40 Chronic Obstructive Pulmonary Disease (COPD) Treatment –Focused history and physical exam –Complains of trouble breathing. Airway control w/ adequate ventilation Oxygenation –Has a prescribed inhaler available. Consult medical direction. Facilitate administration of inhaler Repeat as indicated. –Baseline vital signs. –Reassess

41 Washington EMT-B CPAP Curriculum41 Asthma Defined –Condition which causes the bronchi to constrict making it difficult to exhale (air trapping) –May be caused by allergic reactions and/or emotional distress –The most serious form, status asthmaticus, is a true life-threatening emergency

42 Washington EMT-B CPAP Curriculum42 Asthma Signs/Symptoms/Assessment –Dyspnea, chest tightness, wheezing, and cough –Obvious SOB, wheezing, accessory muscle use, paradoxical respirations, hyperresonance, prolonged expiration –Change in Mental Status: agitation, confusion, lethargy, exhaustion –Cardiac Arrhythmias

43 Washington EMT-B CPAP Curriculum43 Asthma Treatment –Focused history and physical exam –Complains of trouble breathing. Airway control w/ adequate ventilation Oxygenation –Has a prescribed inhaler available. Consult medical direction. Facilitate administration of inhaler Repeat as indicated. –Baseline vital signs. –Reassess

44 Washington EMT-B CPAP Curriculum44 Pneumonia Defined –Inflammation of both the bronchioles and alveoli –May be viral, bacterial, or fungal. Spread by droplets or contact with infected person –Common cause of death in North America

45 Washington EMT-B CPAP Curriculum45 Pneumonia Signs/Symptoms/Assessment –Acute onset of chills, fever, dyspnea, pleuritic chest pain, cough, adventitious breath sounds. –In geriatric patients, the primary sign may be an altered mental state.

46 Washington EMT-B CPAP Curriculum46 Pneumonia Treatment –Focused history and physical exam –Complains of trouble breathing. Airway control w/ adequate ventilation Oxygenation –Has a prescribed inhaler available. Consult medical direction. Facilitate administration of inhaler Repeat as indicated. –Baseline vital signs. –Reassess

47 Treatment with CPAP

48 Washington EMT-B CPAP Curriculum48 Essential Components Of A CPAP System 1. CPAP Control Unit

49 Washington EMT-B CPAP Curriculum49 Essential Components Of A CPAP System 2. Breathing Circuit and Positive Pressure Face Mask

50 Washington EMT-B CPAP Curriculum50 Essential Components Of A CPAP System 3. Oxygen Source

51 Washington EMT-B CPAP Curriculum51 Treatment With CPAP Indications – –Patient in respiratory distress with signs and symptoms consistent with: Congestive Heart Failure (CHF); Pulmonary Edema; asthma; COPD; or pneumonia – –Other measures to improve oxygenation and decrease the work of breathing have failed (i.e., 100% O2 via NRM) – –And who is: Awake and able to follow commands; Is over 12 years of age and is able to fit the CPAP mask; Has the ability to maintain an open airway; – –And Exhibits two or more: – –RR > 25 BPM – –SPO2 <94% at any time – –use of accessory muscles of breathing

52 Washington EMT-B CPAP Curriculum52 Treatment With CPAP Contraindications –Patient is apneic –Patient is suspected of having a pneumothorax –Patient is a trauma patient with injury to the chest –Patient has a tracheostomy –Patient is actively vomiting or has upper GI bleeding

53 Washington EMT-B CPAP Curriculum53 Treatment With CPAP Procedure –Note indications and absence of contraindications –Equipment: CPAP machine CPAP mask, peep valves and straps O 2 Source Pulse Oximetry

54 Washington EMT-B CPAP Curriculum54 Treatment With CPAP Procedure (cont.) –EXPLAIN THE PROCEDURE TO THE PATIENT –Ensure adequate oxygen supply to the CPAP device –Place patient on continuous pulse oximetry –Position head of bed at 45 degrees or patient position of comfort –Place CPAP mask over mouth and nose, secure with straps provided –Use 5 cm H2O of PEEP –Check for air leaks

55 Washington EMT-B CPAP Curriculum55 Treatment With CPAP Procedure (cont.) –Monitor and document the patient’s respiratory response to treatment –Check and document vitals signs every 5 minutes –Assist with appropriate PATIENT PRESCRIBED medication (nitroglycerin tablets for CHF, nebulized Albuterol for COPD/Asthma) –Coach patient to keep mask in place, readjust as needed –Contact Medical Control and / or responding ALS unit to advise of CPAP initiation –Request ALS intercept if available –If respiratory status deteriorates, remove device and consider IPPV via BVM

56 Washington EMT-B CPAP Curriculum56 Treatment With CPAP Patient improvement indicated by: – –Improvement in dyspnea – –Decreased respiratory rate – –Improved pulse oximetry – –Improved patient comfort

57 Washington EMT-B CPAP Curriculum57 Treatment With CPAP Removal –CPAP needs to be continuous and should not be removed unless the patient cannot tolerate the mask or experiences respiratory arrest and/or begins to vomit –Intermittent positive pressure ventilation (IPPV) with a BVM should be considered if CPAP is removed –A Laryngo Tracheal Device (King Airway, Combitube, etc.) should be used with a bag valve device if the patient is in respiratory arrest

58 Washington EMT-B CPAP Curriculum58 Treatment With CPAP Special Considerations –Do not remove CPAP until hospital therapy is ready –Watch for gastric distention which can cause vomiting –CPAP may be used with patients who have POLST forms or DNR orders


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