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Keith Wesley, MD, EMS Medical Director

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1 Keith Wesley, MD, EMS Medical Director
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 CPAP Curriculum – EMT Basic
Introduction Review of Anatomy and Physiology CPAP Overview Pulse Oximetry Review of Respiratory Distress Treatment With CPAP Washington EMT-B CPAP Curriculum

3 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 Washington EMT-B CPAP Curriculum

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

5 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. Washington EMT-B CPAP Curriculum

6 CPAP vs. Intubation CPAP Intubation 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 Washington EMT-B CPAP Curriculum

7 Review of Anatomy & Physiology

8 Elements of the Airway UPPER AIRWAY Nares Nasopharynx Oropharynx
Tongue Epiglottis/Glottis Vocal Cords LOWER AIRWAY Trachea/Esophagus Carina Main stem Bronchi Secondary Bronchi Bronchioles Alveoli Elements of the Airway and the differences between the upper and lower airway. Washington EMT-B CPAP Curriculum

9 Upper Airway Washington EMT-B CPAP Curriculum Teaching points:
Identify each major structure or point and ask students to name: Nasopharynx Oropharynx Epiglottis Ask students how each structure can make airway management difficult Washington EMT-B CPAP Curriculum

10 Pharynx Nasopharynx Oropharynx
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 Review each structure and its associated role in the airway Washington EMT-B CPAP Curriculum

11 Larynx Three main functions:
Air passageway between the pharynx and lungs Prevents solids and liquids from entering the respiratory tree Involved in speech production Primarily to protect us from aspiration Washington EMT-B CPAP Curriculum

12 Larynx An outer casing of nine cartilages Hyoid bone
Thyroid cartilage Cricoid cartilage Only complete cartilaginous ring in the larynx Epiglottis Hyoid bone Cricothyroid membrane Vocal cords Solid structure which usually maintains its integrity Washington EMT-B CPAP Curriculum

13 Lower Airway Washington EMT-B CPAP Curriculum
Point out major structures: Trachea Bronchi Carina Pleura Glottis individual lobes of the lung (2 left & 3 right) sternal notch clavicles apices of the lungs in relation to clavicles note location of heart (not shown) diaphragm location note epiglottis and location of stomach Washington EMT-B CPAP Curriculum

14 Washington EMT-B CPAP Curriculum

15 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 Review the external landmarks Washington EMT-B CPAP Curriculum

16 Pleural Cavity A separate pleural cavity surrounds each lung
Two layers (visceral and parietal) Pleural space Important to stress that a pneumothorax is air in the “potential” space between the visceral and parietal pluera Washington EMT-B CPAP Curriculum

17 Respiratory System - Physiology
The respiratory system functions as a gas exchange system Oxygen is diffused into the bloodstream for use in cellular metabolism Stress the importance of this blood/air interface the mechanism of gas exchange Washington EMT-B CPAP Curriculum

18 Respiratory System - Physiology
Wastes, including carbon dioxide, are excreted from the body via the respiratory system While the chemistry is not important, it is vital that the EMT understand that the PRIMARY means of the body ridding itself of acids produced from metabolism is at the alveoli. Important to stress that if ventilation is impaired, carbon dioxide increases and results in increased acid levels in the blood. Washington EMT-B CPAP Curriculum

19 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 It is only the tidal volume which is involved in gas exchange. Washington EMT-B CPAP Curriculum

20 Inspiration and Expiration
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 Have the student breath in and out and review the motor activity associated with ventilation. Washington EMT-B CPAP Curriculum

21 Pressure Changes During Inspiration and Expiration
Ask the student to describe how the pressure gradients in the chest could be affected by various diseases. Washington EMT-B CPAP Curriculum

22 Mechanics of Breathing
What kind of conditions could inhibit the movement of the diaphragm? Stroke Obesity Lying flat Abdominal trauma (blood, air) Washington EMT-B CPAP Curriculum

23 Mechanics of Respiration
Washington EMT-B CPAP Curriculum

24 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 A patent airway is fundamental for ventilation to occur. CPAP can help but it cannot create a patent airway where none of these components exists. Washington EMT-B CPAP Curriculum

25 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 Diffusion is where gas exchange occurs. What conditions could affect these components? Atherosclerosis Anemia Scarring of the alveoli (COPD) Interstitial fluid (CHF) Washington EMT-B CPAP Curriculum

26 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 Washington EMT-B CPAP Curriculum

27 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 Washington EMT-B CPAP Curriculum

28 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. Washington EMT-B CPAP Curriculum

29 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. Washington EMT-B CPAP Curriculum

30 Review of Respiratory Distress

31 Respiratory Distress Work of Breathing Appearance = Mental Status
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 Work of Breathing Increased respiratory rate is a compensatory response to hypoxia and hypercarbia Appearance The mental status is very sensitive to hypoxia and hypercarbia Circulation/Skin Color The absence of cyanosis DOES NOT mean the absence of respiratory distress Washington EMT-B CPAP Curriculum

32 Focused History and Physical
Ascertain the patient’s chief complaint that may include: Dyspnea Chest pain Cough Productive Non-productive Hemoptysis Wheezing Signs of infection Fever, chills Increased sputum production Taking a good history and performing a thorough exam is critical! Washington EMT-B CPAP Curriculum

33 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 Ask the patient about their medical history. More often than not they will tell you what is wrong with them! Washington EMT-B CPAP Curriculum

34 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 Washington EMT-B CPAP Curriculum

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

36 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 Washington EMT-B CPAP Curriculum

37 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 Washington EMT-B CPAP Curriculum

38 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 Washington EMT-B CPAP Curriculum

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

40 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 Washington EMT-B CPAP Curriculum

41 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 Washington EMT-B CPAP Curriculum

42 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 Washington EMT-B CPAP Curriculum

43 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 Washington EMT-B CPAP Curriculum

44 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 Washington EMT-B CPAP Curriculum

45 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. Washington EMT-B CPAP Curriculum

46 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 Washington EMT-B CPAP Curriculum

47 Treatment with CPAP

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

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

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

51 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 Washington EMT-B CPAP Curriculum

52 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 Washington EMT-B CPAP Curriculum

53 Treatment With CPAP Procedure
Note indications and absence of contraindications Equipment: CPAP machine CPAP mask, peep valves and straps O2 Source Pulse Oximetry Washington EMT-B CPAP Curriculum

54 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 Washington EMT-B CPAP Curriculum

55 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 Washington EMT-B CPAP Curriculum

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

57 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 Washington EMT-B CPAP Curriculum

58 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 Washington EMT-B CPAP Curriculum

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