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 Revised for B/F Counties 2014

2. CPAP Curriculum – EMT Basic Introduction Review of Anatomy and Physiology CPAP Overview Pulse Oximetry Review of Respiratory Distress Treatment With CPAP Revised for B/F Counties 2014

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 Revised for B/F Counties 2014

4. Why CPAP? Respiratory Distress is a common reason why people call 911! Established therapeutic alternative Easily applied, easily discontinued Revised for B/F Counties 2014

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. Revised for B/F Counties 2014

6. CPAP vs. Intubation CPAP –Non-invasive –Easily discontinued –Easily adjusted –Used by EMT, AEMT or paramedic –Does not require sedation –Comfortable Intubation –Invasive –Usually don’t extubate in field –Potential for infection –Requires highly trained personnel –Can require sedation –Traumatic Revised for B/F Counties 2014

7. Review of Anatomy & Physiology Keep in mind, CPAP is for breathing – not airway. Revised for B/F Counties 2014

8. Elements of the Airway UPPER AIRWAY NaresNasopharynxOropharynxTongueEpiglottis/Glottis Vocal Cords LOWER AIRWAY Trachea/EsophagusCarina Main stem Bronchi Secondary Bronchi BronchiolesAlveoli Revised for B/F Counties 2014

9. Upper Airway Revised for B/F Counties 2014

10. 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 Revised for B/F Counties 2014

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 Revised for B/F Counties 2014

12. 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 Revised for B/F Counties 2014

13. Lower Airway Revised for B/F Counties 2014

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 Revised for B/F Counties 2014

16. Pleural Cavity A separate pleural cavity surrounds each lung Two layers (visceral and parietal) Pleural space Revised for B/F Counties 2014

17. Respiratory System - Physiology The respiratory system functions as a gas exchange system Oxygen is diffused into the bloodstream for use in cellular metabolism Revised for B/F Counties 2014

18. Respiratory System - Physiology Wastes, including carbon dioxide, are excreted from the body via the respiratory system Revised for B/F Counties 2014

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 Revised for B/F Counties 2014

20. 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 Revised for B/F Counties 2014

21. Pressure Changes During Inspiration and Expiration Revised for B/F Counties 2014

22. Mechanics of Breathing Revised for B/F Counties 2014

23. Mechanics of Respiration Revised for B/F Counties 2014

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 Revised for B/F Counties 2014

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 Revised for B/F Counties 2014

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 Revised for B/F Counties 2014

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 Revised for B/F Counties 2014

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. Revised for B/F Counties 2014

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. Revised for B/F Counties 2014

30. Review of Respiratory Distress Revised for B/F Counties 2014

31. 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

32. Respiratory Distress Circulation/Skin Color –Severe cyanosis –Pallor and diaphoresis Revised for B/F Counties 2014

33. 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 Revised for B/F Counties 2014

34. 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 Revised for B/F Counties 2014

35. 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 Revised for B/F Counties 2014

36. Pulmonary Edema – Congestive Heart Failure Signs/Symptoms/Assessment –Fatigue –Nocturia –Dyspnea on exertion –Paroxysmal nocturnal dyspnea –Chest Pain –Orthopnea Revised for B/F Counties 2014

37. 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 PER your Protocols –Baseline vital signs. –Reassess Revised for B/F Counties 2014

38. 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 Revised for B/F Counties 2014

39. 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 Revised for B/F Counties 2014

40. Chronic Obstructive Pulmonary Disease (COPD) Signs/Symptoms/Assessment –Tachypnea, cyanosis, agitation, tachycardia, hypertension –Confusion, tremor, stupor, apnea Revised for B/F Counties 2014

41. 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 Revised for B/F Counties 2014

42. 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 Revised for B/F Counties 2014

43. 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 Revised for B/F Counties 2014

44. 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 Revised for B/F Counties 2014

45. 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 Revised for B/F Counties 2014

46. 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. Revised for B/F Counties 2014

47. 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 Revised for B/F Counties 2014

48. Treatment with CPAP Revised for B/F Counties 2014

49. Components of a CPAP Circuit Revised for B/F Counties 2014

50. Components of a CPAP Circuit Trio Control unit allows for control of the fractional inspired oxygen (FiO2) -The control unit can be set at 30%, 60%, OR 90%+ FiO2 Revised for B/F Counties 2014

51. Components Of A CPAP System Oxygen Source Revised for B/F Counties 2014

52. Assembled CPAP with Trio Control Revised for B/F Counties 2014

53. VIDEOS: Pulmodyne O2 Max Revised for B/F Counties 2014 http://www.youtube.com/watch?v=IVIoHXN_zCA http://paramedictv.ems1.com/fireems- videos/2789145373001-o2max-trio-system- overview/ Click on Pictures to view videos.

54. 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 Revised for B/F Counties 2014

55. 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 Revised for B/F Counties 2014

56. Treatment With CPAP Procedure –Note indications and absence of contraindications –Equipment: CPAP machine CPAP mask, peep valves and straps O 2 Source Pulse Oximetry Revised for B/F Counties 2014

57. 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 Revised for B/F Counties 2014

58. 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 Revised for B/F Counties 2014

59. Treatment With CPAP Patient improvement indicated by: – –Improvement in dyspnea – –Decreased respiratory rate – –Improved pulse oximetry – –Improved patient comfort Revised for B/F Counties 2014

60. 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 Revised for B/F Counties 2014

61. 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 Revised for B/F Counties 2014