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7/31/2019 CPAP-1

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Virginia Beach EMS

Oxy-PEEP C-PAPEric de Forest, NREMT-P

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C-PAP Overview

?Applies continuous pressure to airways

to improve oxygenation.

?Bridge device to improve oxygenationuntil underlying cause of the respiratory

distress can be treated.

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With any new subject, you’ve got

to learn the lingo

? NIPPV

? NIPSV

? C-PAP

? Bi-PAP

? I-PAP

? E-PAP? PEEP

? FiO2

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to learn the lingo

? NIPPV Non-invasive positive pressure

ventilation

? NIPSV Non-invasive pressure supportventilation

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to learn the lingo

? C-PAP Continuous positive airway pressure

? Bi-PAP Bi-level positive airway pressure

? I-PAP Inspiratory positive airway pressure

? E-PAP Expiratory positive airway pressure

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to learn the lingo

? PEEP Positive end-expiratory pressure

? FiO2 Fraction of inspired air

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C-PAP vs. PEEP

? C-PAP non-invasive

? PEEP for intubated

patients

? Terms usedinterchangeably

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C-PAP vs. Bi-PAP

? C-PAP

– Continuous pressure

– 5-20 cm H2O

? Bi-PAP

– Alternating pressure

– More with inspiration

10 cm H2O

– Less with expiration5 cm H2O

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Upper Airway?Mouth/Nose

?Oro/Nasopharynx

? Pharynx

? Epiglottis

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Lower Airway? Larynx

? Trachea

?Main Bronchi (R/L)

? Bronchioles

? Alveoli

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Alveolar Capillary Beds

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Normal Breathing

?Muscles

– Diaphragm

– Accessory Muscles

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Inspiration

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Expiration

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Control of Breathing

? CO2 Level in

Arterial Blood

? Hypoxic Drive

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Gas Exchange

?Ventilation

?Diffusion

?Perfusion

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Ventilation

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Diffusion

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Perfusion

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Congestive Heart Failure

? Left Ventricular

failure causes blood

to back up – Pulmonary

circulation (capillarybeds)

– Interstitial tissues – Alveoli

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Congestive Heart Failure

? Pulmonary edema

interferes with

oxygen crossingalveolar/capillary

membrane

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Congestive Heart Failure? Pulmonary edema

washes out

surfactant – Increased work of

breathing tomaintain openalveoli

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CHF Infection? Bilateral rales or

crackles

? Clear or pinksputum

? Uni-lateral rales or

crackles

? Fever

? Productive coughwith green/yellow

sputum

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COPD

?Chronic Obstructive Pulmonary Disease

– Emphysema

– Chronic Bronchitis

– Asthma

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Emphysema? Loss of elasticity of

lung tissue

– Difficulty exhaling• Air trapping

• CO2 retention

? Break down ofalveolar walls

– Decrease surfacearea for gasexchange

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Chronic Bronchitis

? Chronic

Inflammation of

bronchiole tree withincreased mucous

production

? Difficulty exhaling

– Air trapping – CO2 retention

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Asthma

? Intermittent

Bronchoconstriction

? Difficulty exhaling – Air trapping

– CO2 retention

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Physiological Benefits of C-PAP

? Increase in alveolar pressure

– Stop fluid movement into alveoli

– Improves gas distribution

– Prevents alveolar collapse

– Improves re-expansion of alveoli

?Reduces work of breathing?Reduces respiratory muscle fatigue

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Physiological Benefits of C-PAP

? Increases intrathoracic pressure

– Improves cardiac output to a point

– Too much PEEP decreases cardiac output

?Decreases need for intubation and

associated complications

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Hazards/Complications of C-PAP

?Airway

– Mask impairs access to patient’s airway

– C-PAP does not ventilate the patient

– Gastric distension / vomiting

• Aerophagia (swallowing air) sensitive patients

– Gastric stapling

– Upper GI surgery

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?Hypoxia

– Loss of oxygen supply

• Empty oxygen tank

• Disconnection of Oxy-PEEP from oxygensource

– Mask Leak

– Rebound hypoxia may be more severethan initial hypoxia

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Calculate Oxygen Duration

(Tank PSI – safe residual) X cylinder constant = minutes

LPM

Portable Cylinders

Cylinder – Flow 1000 PSI 1500 PSI 2000 PSI

D – 15 LPM 8.5 min 13.8 min 19.2 min

D – 25 LPM 5.1 min 8.3 min 11.5 min

E – 15 LPM 14.9 min 24.3 min 33.6 min

E – 25 LPM 9 min 14.6 min 20.2 min

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Calculate Oxygen Duration

(Tank PSI – safe residual) X cylinder constant = minutes

LPM

Main Cylinders

Cylinder – Flow 500 PSI 1000 PSI 1500 PSI

M – 15 LPM 31 min 83 min 135 min

M – 25 LPM 18 min 50 min 81 min

G – 15 LPM 48 min 129 min 209 min

G – 25 LPM 29 min 77 min 125 min

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?Hypotension

– Increased intrathoracic pressure causes

• Decreased venous return

• Decreased cardiac output

– Increased pulmonary pressure causes

• Decreased blood flow through pulmonaryvessels

• Decreased cardiac output

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? Barotrauma

– High alveolar

pressures can causeover-inflation of lung

resulting in

• Pneumothorax

• Pneumomediastinum

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Concerns using C-PAP with

COPD? Increased Air

Trapping

? Hypotension? Barotrauma

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?More PEEP is NOT necessarily better

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?More PEEP is NOT necessarily better

– If 5 cm H2O PEEP is good it DOES NOT mean

that 10 cm H2O is better!!!

– Most patients will respond to 5 cm H2O PEEP

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?Patient Discomfort

– Requires patient cooperation to tolerate a

tightly fitting mask• Sensation of smothering or claustrophobia

– Use trial to introduce patient to device prior

to securing head strap

– Consider sedation for extreme anxiety withorders from Medical Control

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Oxy-PEEP C-PAP

? Equipment

– Mask

– FiO2 dial – Reservoir bag

– Air intake valve

– PEEP valve

– Head strap

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Mask

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FiO2 Dial

? Range 32-95%

? LPM

– Minimum 15 LPM

– Maximum: flush

(25 LPM)

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FiO2 dial

? Initial application -

Set at 95%

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FiO2 dial

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Reservoir Bag

? Fill before applying

C-PAP to patient

? Self-fills at FiO295%

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Air Intake Valve

? At lower FiO2,

allows room air to

be drawn intosystem

? C-PAP benefits

primarily come from

pressure not oxygenconcentration

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PEEP Valve

? Range 5-20 cmH2O

? PEEP valve

accurate +/- 2cmH2O

– Manufacturerrecommends

checking againstmanometer pressure

gauge

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PEEP Valve

? Factory setting lessthan 5 cm H2O

? Verify that cap turneasily but will holdits setting

? Turn cap so bottomedge is on desiredsetting – Initial 5 cm H2O

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Head Strap

? Apply to patient’s

head after patient

accepts C-PAP

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Patient Criteria to Use Oxy-PEEP

?Old enough to get adequate mask seal

– Recommended for patients 18 years or

older

?Alert with intact airway and ventilatory

drive

?Systolic BP at least 90 mmHg

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? Sudden onset of respiratory distress frompulmonary edema. S/S include

– Anxiety/restlessness – Dyspnea with s/s hypoxia• Verbal complaint

• 1-2 word dyspnea

• Accessory muscle use

• Tachypnea

• Tachycardia

• Pallor (pale)

• Cyanosis

• Diaphoresis

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?Frothy sputum (may be pink)

?Room air SpO2 < 94%

?Bilateral crackles / rales

?Peripheral edema

?Chest pain

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Absolute Contraindications

? Inadequate airway

or respiratory drive

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? Need for immediate

airway control

(intubation)

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? Hemodynamic

instability

– Systolic BP <90 mmHg

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? Aspiration risk

– Vomiting or severe

nausea

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Relative Contraindications

? Upper airway or

facial abnormalities

or trauma thatinterfere with mask

seal

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? Uncooperative

patient

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?Respiratory distress caused by

– Aspiration

– Asthma (requires MD orders)

– COPD (requires MD orders)

– Pneumonia

– Pneumothorax

– Anaphylaxis – Pulmonary embolism

– Respiratory Burns

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Procedure

?Assess patient for S/S pulmonary

edema

?Room Air SpO2 < 94%

?Systolic BP at least 90 mmHg

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Procedure

? Implement CHF branch of Difficulty Breathingprotocol

?May be done simultaneously with application

of C-PAP – High flow O2 via NRB until C-PAP applied

– Monitor / IV

– Nitroglycerin 0.4 mg SL X3• Once C-PAP applied, unfasten mask to administer Ntg

– Lasix 40 mg IV – Albuterol HHN if wheezing

– Morphine 2-4 mg slow IV every 5 minutes up to10 mg total

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Procedure

?Prepare C-PAP Equipment

– Adjust FiO2 to 95%

– Set PEEP at 5 cm H2O

– Set O2 flow at flush (minimum 15 LPM)

– Fill reservoir bag

– Prepare intubation equipment – Ensure adequate supply of oxygen (main

and portable)

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Procedure

?Prepare Patient

– Position Stretcher at 45 degrees or higher

– Inform patient of procedure

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Procedure

?Mask Application – Trial to introduce device

• Explain patient will feel positive oxygenpressure

– Hold mask gently on patient’s faceensuring good seal

– Once patient accepts mask, secure maskwith straps

– Deflate mask as needed to get good seal

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Procedure

?On-Going Care / Monitoring – Reassess at least every 5 minutes

• Patient’s impression of difficulty breathing• Vital signs

• Lung sounds

• SpO2

– Observe for complications• Hypotension

• Barotrauma

• Worsening dyspnea

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Procedure

? If patient continues to have severe

difficulty breathing after 5 minutes,

consider increasing PEEP to 10 cmH2O

– Systolic BP must be at least 90 mmHg

– CAREFULLY watch for complications ofincreased PEEP

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Procedure

?On-Going Care / Monitoring

– Oxygen conservation

• If patient is improved with C-PAP – SpO2 > 94%

– Work of breathing improved

• Consider decreasing LPM to 15

• Make sure reservoir bag remains full• Carefully monitor patient status including SpO2

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Discontinuing C-PAP

?C-PAP usually is not discontinued in the

field

?High PEEP level may require weaning

?Rebound hypoxia can be worse thaninitial hypoxia

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Discontinuing C-PAP

?Patient requires BVM or intubation

– Remove C-PAP, ventilate and intubate

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Discontinuing C-PAP

?Need to suction airway

– Remove C-PAP, suction, reapply C-PAP

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Discontinuing C-PAP

?BP drops below 90 mmHG

– Contact Medical Control

– Is High PEEP worsening patient’s

condition? OR

– Is the underlying pathology causing the

deterioration?

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Discontinuing C-PAP

?Consider decreasing PEEP with ordersfrom Medical Control – Patient hemodynamically stable at 5 cm

H2O PEEP

– PEEP increased to 10 cm H2O and BPdropped

– Is High PEEP worsening patient’s condition

or is the underlying pathology causinghypotension?

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Protocol Use

? Included in A/O/V and Difficulty

Breathing Protocols

?Standing order for CT/I/P to use forCHF induced pulmonary edema

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Protocol Use

? Initial PEEP 5 cm H2O

?FiO2 95%

?Standing order to increase to 10 cm

H2O if patient in severe distress and notimproving after 5 minutes

– Most patients will respond to 5 cm H2OPEEP

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Documentation – It IS Your Job

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Documentation

? Document Use under “Other”

– Not positive pressure ventilation

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Documentation - Narrative

? Patient’s S/S including SpO2

? S/S indicating CHF vs. COPD to rule inC-PAP use

– C-PAP use for COPD requires orders fromMedical Control

? C-PAP settings – FiO2

– PEEP

– O2 LPM

– Any changes in settings and why

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Documentation

? Treatments to correct underlying pathology

? Patient’s response to C-PAP and other

treatments

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Questions????

- D. Brennaman: Initial Author

cpap-1

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