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Continuous Positive Airway Pressure For EMT Providers State Education & Training Committee December 2012

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Page 1: Cpap final 2012_12 (2)

Continuous Positive Airway Pressure

For EMT Providers

State Education & Training CommitteeDecember 2012

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Goal

The student will be able to correctly utilize service specific CPAP devices in a respiratory compromised patient

[img]http://hammondems.com/images/d_1976.jpg

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Objectives

At the completion of this training, the BLS provider will: Describe respiratory anatomy and physiology Verbalize understanding of respiratory

disorders / illnesses Appreciate the benefits and limitations of

CPAP in alleviating patient symptoms List indication and contraindications for use.

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Anatomy and Physiology of Respiration

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Respiratory Physiology

Nose / Mouth Trachea Mainstem Bronchi Secondary Bronchi Tertiary Bronchi Bronchioles Terminal Bronchiole Alveoli Diaphragm

http://www.uni.edu/schneidj/webquests/spring04/offtowar/respiratory.html

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InhalationInhalation

Active process Negative

pressure pulls air into lungs

continued

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Exhalation

Passive process Muscles relax;

size of chest decreases

Positive pressure created; air pushed out

continued

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Negative Pressure

Respiration driven by process of negative intrathoracic pressures Negative pressure

Initiates inhalation and acquires O2

Assists to increase intrathoracic blood flow

Equalization of pressures initiates exhalation and elimination of CO2

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Alveoli

Expand and contract with breathing Contact with pulmonary capillary beds for gas

exchange Inside surface coated with surfactant

Prevents aveoli from sticking together Keeps alveoli open

Atelectasis

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Mechanics of Respiration

http://www.teachpe.com/anatomy/respiratory_system.php

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Functional Residual Capacity

Lung volume at end of normal exhalation

Muscles of respiration are completely relaxed

http://www.lakesidepress.com/pulmonary/htm

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Gas Exchange

http://www.uic.edu/classes/bios/bios100/lectures/circ.htm

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Oxygenation

Process of getting oxygen to end organs and tissues Inhaled through lungs Picked up from alveoli on RBCs Off-loaded in exchange for CO2

Measured by pulse oximetry (SpO2)94%-100%

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Ventilation

Process to eliminate carbon dioxide (waste product of energy production) Carried back through venous blood Eliminated through exhalation

Measured by capnography

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Respiratory Disorders

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Respiratory Disorders

A combination of many disease processes responsible for emergencies related to

ventilation, diffusion and perfusion.

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Respiratory Distress

Subjective indication of some degree of difficulty breathing Causes

Upper or lower airway obstruction Inadequate ventilation Impaired respiratory muscle function Impaired nervous system Trauma Bronchitis, pneumonia, cancer

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Respiratory Failure

Clinical state of inadequate oxygenation, ventilation or both.

Often end-stage of respiratory distress Signs:

Tachypnea (early) Bradypnea or apnea (late) Increased, decreased, or no respiratory effort Tachycardia (early) Bradycardia (late) Cyanosis Altered Mental Status

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Mechanism of Heart Failure

Frequently a chronic, yet manageable condition

Left ventricle fails to work as effective pump (Left-Sided CHF)

Blood volume backs up into pulmonary circulation

Most often caused by: Volume overload Pressure overload Loss of myocardial tissue

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Pulmonary Edema

Cardiac and respiratory system impairment Acute and critical emergency Filling of lungs with fluid

Washes away surfactant Lipids & Proteins Prevents collapse of alveolus at low lung

volume Creates pink froth in sputum

Prevents alveoli from expanding Significantly reduces or eliminates ability for gas

exchange to occur

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Asthma

Reactive airway disorder Exacerbation precipitated by extrinsic or

intrinsic factors Characterized by reversible bronchial smooth

muscle contraction, increased mucus production and inflammatory airway changes

Persistent signs and symptoms can indicate a tenfold increase in the work of breathing

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Asthma

Evolution of asthma attack Mucus thickens and

accumulates plugging airways

Mucosal edema develops

Muscle spasms constrict small airways

Breathing becomes labored

http://asthma-ppt.com/asthma-pictures.html

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Caution

Asthma Anaphylaxis

Causes Smoke, dander, dust, pollen, cold air, mold, cleaning products, perfume, exercise

Nuts, shellfish, milk, eggs, soy, wheat, insect stings, medications, latex

Symptoms WheezingCoughingShortness of breathDifficulty breathingChest tightness

Face - itchiness, redness, swelling of face & tongueAirway – trouble breathing, swallowing or speakingStomach – abdominal pain, vomiting, diarrheaTotal hives, rash, itchiness, swelling, weakness, pallor, sense of doom, loss of consciousness

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Chronic Obstructive Pulmonary Disease

Obstructive lung disease Triad of distinct diseases that often coexist

Asthma Chronic bronchitis Emphysema

Traditionally refers to patients with combination of chronic bronchitis and emphysema

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Chronic Bronchitis

Bronchi become filled with excessive mucus Alveoli are not affected Diffusion of gas remains relatively normal

Patients develop low oxygen pressures (PO2) and hypoventilation

Hypoventilation leads to high levels of CO2

and low levels of O2

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Emphysema

Results from pathological changes in the lung Permanent abnormal

enlargement of air spaces beyond terminal bronchioles

Collapse of the bronchioles

Destruction of the alveoli

http://health.allrefer.com/health/chronic-obstructive-pulmonary-disease-emphysema.html

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Emphysema

Patients have some resistance to airflow, primarily on exhalation Hyper-expansion

caused by air trapped in the alveoli

Breathing becomes an active process

Sanders, M.J. (2005) Paramedic Textbook (3rd ed.) St. Louis: Mosby-Elsevier

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Emphysema

Risk of pneumothorax Interior airway pressure

CO2 Retention Potential worsening with CPAP

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ContinuousPositiveAirway

Pressure

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The use of CPAP prehospitally reduces the need for intubation by 30% and reduces mortality by 20%

Annals of Emergency Medicine, September 2008

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CPAP

Non-invasive ventilation

Continuous O2

delivered at a set positive pressure throughout the respiratory cycle

www.ems1.com/cpap-for-ems

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Positive Pressure

PUSHES air into the chest Overcomes airway resistance

Bag valve mask Demand valve Intubation / mechanical ventilation CPAP

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Effects of CPAP

Increases functional residual capacity

Increases alveolar surface area available for gas exchange

Increases oxygen diffusion across alveolar membranes

Reduced work of breathing

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Indications

Severe Respiratory Distress / Respiratory Failure Accessory muscle use? Persistent hypoxia despite appropriate /

aggressive oxygen therapy? Marked increased work of breathing? Inability to speak full sentences?

Differentiate Pulmonary Edema versus other Respiratory Disorder

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Contraindications

Respiratory rate < 10 breaths / minute Systolic blood pressure < 100 mmHg Confusion

Inability to understand directions and cooperate with application of CPAP

History of pneumothorax History of recent tracheo-bronchial surgery

Active nausea or vomiting Unconscious Facial Injuries

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How CPAP Works

Maintains constant level of airway pressure

Keeps and maintains alveoli open.

Moves fluid into vasculature (pulmonary edema)

Improves gas exchange

Buys time for medications to work

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PEEP & Fi02

Positive End-Expiratory Pressure The purpose of PEEP is to increase the volume of gas

remaining in the lungs at the end of expiration in order to decrease the shunting of blood through the lungs and improve gas exchange.

Fraction of inspired oxygen The fraction or percentage of oxygen in the space being

measured. Natural air includes 20.9% oxygen, which is equivalent to

FiO2 of 0.21. Each additional liter of oxygen adds about 4% to their FiO2

Peep

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Procedure

Prepare C-PAP Equipment – Adjust FiO2 to 95% – Set PEEP at 5 cm H2O – Set O2 flow at (minimum 15 LPM) – Ensure adequate supply of oxygen (main and portable) Reassess patient every 5 minutes

If patient continues to have severedifficulty breathing after 5 minutes,

consider increasing PEEP to 10 cm

H2O

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Limitations

CPAP is not a mechanical ventilator

Tight mask seal can create claustrophobic response Consider allowing patient to self-seal (hold

own mask) until initial benefits recognized

CPAP is powered by on-board oxygen supply

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Oxygen Utilization

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

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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Summary

Pre-hospital studies have proven the effectiveness of CPAP in treating patients with severe respiratory distress, regardless of disease process.

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ANY

QUESTIONS

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Practical

Skills

Session