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