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GRANT COUNTY APRIL 2014 CPAP BASICS.  Establish a protocol for Continuous Positive Airway Pressure usage for pre-hospital respiratory distress  Discuss.

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Presentation on theme: "GRANT COUNTY APRIL 2014 CPAP BASICS.  Establish a protocol for Continuous Positive Airway Pressure usage for pre-hospital respiratory distress  Discuss."— Presentation transcript:


2  Establish a protocol for Continuous Positive Airway Pressure usage for pre-hospital respiratory distress  Discuss the basic principles of Continuous Positive Airway Pressure and its application  Review the physiological effects of CPAP  Discuss the indications and contraindications of CPAP usage OBJECTIVES

3  “Learn the Lingo”  NIPPV: Non-Invasive Positive Airway Pressure  Includes BiPAP, CPAP, Bag valve mask  Continuous Positive Airway Pressure (CPAP)  What we will be using  Bi-Level Positive Airway Pressure (Bi-PAP)  Often used in the hospital once the patient arrives  PEEP: Positive End Expiratory Pressure  A value we can measure on ventilated patients (ie, closed circuit)  Both BiPAP and CPAP provide a small amount of PEEP DEFINITIONS

4  BiPAP  Continuous Pressure  Pressures are different between inhalation and exhalation (ie, 12/8 cm/H20)  Not commonly used in the field or at home due to the complexity of delivery/devices  Needs monitoring of delivered pressures  Expensive  CPAP  Continuous Pressure  Same pressure during exhalation and inhalation  Used in the field and at home  Less complicated devices for delivery  Needs little monitoring  Set it and it’s good  Cheaper BIPAP VS CPAP

5  Continuous positive pressure delivery system  Provides more airway pressure than a non-rebreather mask but less than BVM  Similar to sticking your head out of a window while traveling at highway speeds CPAP

6  Non-invasive  Easily Applied  Easily Removed  Useful for many types of respiratory distress  CHF, COPD, Asthma, Pneumonia, Near drownings  Able to give nebs and other medications “in-line” or while it is applied  Can serve as a “bridge” to give patients extra respiratory support as the other medications and treatments have time to take effect (ie. Nitro/lasix, duonebs, steroids, etc)  Can help avoid intubations for patients that are likely to rapidly improve with adjunct treatments CPAP USAGE ADVANTAGES

7  “Alternative” to ETT Intubation  Some patients are not great candidates for intubations or are frail and likely to have a difficult extubation  Prospective randomized trials have shown 50-70% of patients with a severe COPD exacerbation who receive non-invasive ventilation can avoid intubation  Prehospital use of CPAP for moderate-severe respiratory failure has been proven effective  Reduction in intubation rate of 30%  Absolute Reduction in mortality of 21% In appropriately selected patients who received CPAP instead of usual care (intubation)  COPD patients who are intubated typically are ventilator dependent for longer periods (difficult to extubate), causes increased morbidity with pneumonia risk and risk for spontaneous pneumothorax CPAP ADVANTAGES

8  Positive Pressure!  Redistributes lung fields (inflates)  Reduces work of breathing  Counteracts intrinsic PEEP  Pursed lip breathing  Improves Lung Compliance  Reverses Atelectasis  Collapsed alveoli  Decreases Preload/Afterload  Beneficial esp for CHF patients  Decreased V/Q mismatch (ventilation/perfusion)  Improves Gas Exchange WHY CPAP?

9  Ventilation and perfusion mismatch  Causes:  Pulmonary Edema  Pneumonia  Increased dead space (collapsed or atelectatic lung)  Pulmonary embolism  Shunt V/Q MISMATCH

10  Upper Lungs  V>P  Mid Lungs  V=P  Lower Lungs  V

11  Caused by lack of perfusion (ventilation is normal)  Pulmonary embolism  Cardiac arrest  Hypovolemia/shock  Normal phenomenon in dead space  Upper lung, V>P HIGH V/Q RATIO

12  Enough Perfusion, not enough ventilation  Atelectasis  Increased secretions  Mucus plugging  Bronchial intubation  shunt LOW V/Q RATIO

13  Hypothetical pressure of a gas in the atmosphere were it to occupy the same volume of space as the mixture it is in  Air at sea level has a pressure of 1 atmosphere, or 760 mmHg  Air is 21% oxygen at sea level  The partial pressure of room air 02 is 760 x 0.21 = 159 mmHg PARTIAL PRESSURE OF GAS

14  The difference in pressure between a higher concentration of gas and a lower concentration of gas is called a pressure gradient  Gas has a tendency to move from a higher partial pressure to a lower partial pressure until equilibrium is established  This pressure gradient is what causes oxygen to enter the blood and CO2 to leave the blood (gas exchange)  Happens at the alveolar level  Expired air has oxygen content of about 16%, so the parital pressure is 760 mmHg x 0.16 = 121 mmHg  The pressure gradient of oxygen between room air (159mmHg) and blood oxygen (121mmHg) creates a gradient to allow oxygen exchange PRESSURE GRADIENTS

15  CPAP changes the pressure gradient  CPAP is measured by cmH2O  1 cm H2O = mmHg  Typically CPAP is applied at either 5 or 10 cmH2O  This increases the partial pressure by 2.25%  Increased partial pressure of oxygen delivered results in greater differential and improved oxygen exchange  The clinical effects can be impressive with even this small change CPAP AND PRESSURE GRADIENTS

16  Increased airway pressure with CPAP  Stent open airways that are at risk of collapse due to excess fluid or edema  Inflates alveoli and prevents collapse during expiration  Creates greater surface area= better exchange of gases  Decreases the work of breathing by preventing continual collapse of the airways  Patient senses easier breathing, less work esp on inspiration  Maintains gas exchange over a longer period of time MECHANICAL EFFECTS

17  Increased oxygen levels  Reduced work of breathing  Reduced V/Q mismatch PHYSIOLOGICAL EFFECTS OF CPAP

18  Indications: moderate to severe respiratory distress from the following:  Pulmonary edema/CHF (including from near drownings)  Acute Asthma exacerbation not responding quickly to usual treatments  COPD exacerbation failing conventional treatments  Pneumonia GRANT COUNTY PROTOCOL

19  DO NOT USE CPAP IF:  The patient is unconscious or altered  GCS<13-14 or unable to protect their own airway  Hypotensive (SBP <90 mmHg)  Vomiting  Suspected pneumothorax (ensure equal bilateral breath sounds prior to application)  Trauma  Facial abnormalities  Unable to obtain mask seal (large beard, etc)  Extreme caution in pulmonary fibrosis (lowest pressure setting if used)  Dementia (moderate or severe) CONTRAINDICATIONS

20  Know your CPAP device and how to adjust it (many options out there)  Overall goal is to increase airway pressure and improve oxygen delivery/gas exchange  Verbally coach patient, explain the procedure  Apply waveform capnography (ETCO2)  Apply CPAP with pressure of 5-10 cmH20  Coach and reassure the patient (slow, deep breaths)  Watch for resistance and apprehension  Check for leaks around the mask/ensure good seal  Reassess lung sounds and vitals q3-5 minutes PROCEDURE

21  In line nebs can be administered while the CPAP is on  Nitroglycerin may be administered by momentarily lifting the facemask  If the patient becomes more confused or is not tolerating the CPAP mask and still has severe distress, move to ETT intubation or other advanced airway measures PROCEDURE

22  CPAP may cause a drop in blood pressure due to increased intrathoracic pressure  Watch for GI distention, which may lead to vomiting  Patient may become claustrophobic or unwilling to tolerate mask  Sometimes coaching can overcome this, give them direct feedback on inhalation and exhalation  Use with great caution in patients with dementia, must have cognitive ability to understand what CPAP does PRECAUTIONS

23  Proceed to advanced airway for patients with worsening respiratory distress or decreasing level of consciousness  Not for use in children <12 years old  Advise receiving hospital of CPAP application so they can prepare and have respiratory therapy on standby SPECIAL NOTES

24  Pulmonary Edema patients often improve within minutes of application of CPAP  CPAP is to pulmonary edema like D50 is to hypoglycemia  Visual inspection if chest wall movement should demonstrate improved respiratory excusion  Bilateral chest wall movement, retractions, etc  “Look, listen and feel” IMPORTANT POINTS

25  When to do what:  Respiratory distress = increased effort and frequency of breathing in maintaining normal O2 and CO2 in the blood  Respiratory Failure = inability to maintain normal amounts of O2 and CO2 in the blood CPAP VS INTUBATE

26  Signs of respiratory distress:  Tachypnea  Tachycardia  Accessory muscle use  Decreased Tidal Volume  Paradoxical breathing (abdominal muscles)  CPAP can generally be used on these patients RESPIRATORY DISTRESS

27  Declining tidal volume  Irregular or gasping breaths  Poor color = poor perfusion = poor oxygen exchange  Not likely to improve without invasive measures  Decline in LOC  Hypercarbia  Hypoxemia  High CO2 lowers pH, causing acidosis  Acidosis causes further metabolic changes and ultimately leads to cardiac arrest RESPIRATORY FAILURE

28  CPAP can provide an adjunct to allow medications to take effect (“Buys time”)  CPAP reverses CHF induced pulmonary edema  CPAP can prevent prolonged ventilation that can occur after intubation  Non-invasive = can be used on DNI  Fixes V/Q mismatch, opens airways, increases oxygen pressure gradient, reduces work of breathing SUMMARY

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