cpap final 2012_12

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  • Continuous Positive Airway PressureFor EMT Providers

    State Education & Training CommitteeDecember 2012

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


  • ObjectivesAt the completion of this training, the BLS provider will:Describe respiratory anatomy and physiologyVerbalize understanding of respiratory disorders / illnessesAppreciate the benefits and limitations of CPAP in alleviating patient symptomsList indication and contraindications for use.

  • Anatomy and Physiology of Respiration

  • Respiratory Physiology

    Nose / MouthTracheaMainstem BronchiSecondary BronchiTertiary BronchiBronchiolesTerminal BronchioleAlveoliDiaphragm

  • Negative PressureRespiration driven by process of negative intrathoracic pressuresNegative pressureInitiates inhalation and acquisition of O2Assists to increase intrathoracic blood flow

    Hemodynamic Effects

    Equalization of pressuresinitiates exhalation and elimination of CO2

  • Bronchi / BronchiolesCartilage structures give way to smooth muscle

    May divide up to 25 times before reaching terminal bronchioles


  • AlveoliExpand and contract with breathingContact with pulmonary capillary beds for gas exchangeInside surface coated with surfactantPrevents aveoli from sticking togetherKeeps alveoli openAtelectasis

  • Mechanics of Respiration

  • Functional Residual CapacityLung volume at end of normal exhalation

    Muscles of respiration are completely relaxed

  • Gas Exchange

  • OxygenationProcess of getting oxygen to end organs and tissuesInhaled through lungsPicked up from alveoli on RBCsOff-loaded in exchange for CO2

    Measured by pulse oximetry (SpO2)

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

    Measured by capnography

  • CapnographyThe capnogram wave form begins before exhalation and ends with inspiration. Exhalation comes before inhalation

  • Capnography Waveform;s=pain/management

  • Respiratory Disorders

  • Respiratory DisordersA combination of many disease processes responsible for emergencies related to ventilation, diffusion and perfusion.

  • Respiratory DistressSubjective indication of some degree of difficulty breathingCausesUpper or lower airway obstructionInadequate ventilationImpaired respiratory muscle functionImpaired nervous systemTraumaBronchitis, pneumonia, cancer

  • Respiratory FailureClinical state of inadequate oxygenation, ventilation or both.Often end-stage of respiratory distressSigns:Tachypnea (early)Bradypnea or apnea (late)Increased, decreased, or no respiratory effortTachycardia (early) Bradycardia (late)CyanosisAltered Mental Status

  • Mechanism of Heart FailureFrequently a chronic, yet manageable conditionLeft ventricle fails to work as effective pumpBlood volume backs up into pulmonary circulationMost often caused by:Volume overloadPressure overloadLoss of myocardial tissueImpaired contractility

  • Pulmonary EdemaCardiac and respiratory system impairment Acute and critical emergencyFilling of lungs with fluidWashes away surfactantCreates pink froth in sputumPrevents alveoli from expandingSignificantly reduces or eliminates ability for gas exchange to occur

  • AsthmaReactive airway disorderExacerbation precipitated by extrinsic or intrinsic factorsCharacterized by reversible bronchial smooth muscle contraction, increased mucus production and inflammatory airway changesPersistent signs and symptoms can indicate a tenfold increase in the work of breathing

  • AsthmaEvolution of asthma attackMucus thickens and accumulates plugging airwaysMucosal edema developsMuscle spasms constrict small airwaysBreathing becomes laboredExhalation becomes difficult

  • Caution

    AsthmaAnaphylaxisCausesSmoke, dander, dust, pollen, cold air, mold, cleaning products, perfume, exerciseNuts, shellfish, milk, eggs, soy, wheat, insect stings, medications, latexSymptomsWheezingCoughingShortness of breathDifficulty breathingChest tightnessFace - 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

  • Chronic Obstructive Pulmonary DiseaseObstructive lung disease Triad of distinct diseases that often coexistAsthmaChronic bronchitisEmphysema

    Traditionally refers to patients with combination of chronic bronchitis and emphysema

  • Chronic BronchitisBronchi become filled with excessive mucusAlveoli are not affectedDiffusion of gas remains relatively normalPatients develop low oxygen pressures (PO2) and hypoventilationHypoventilation leads to high levels of CO2 and low levels of O2

  • EmphysemaResults from pathological changes in the lungPermanent abnormal enlargement of air spaces beyond terminal bronchiolesCollapse of the bronchiolesDestruction of the alveoli

  • EmphysemaPatients have some resistance to airflow, primarily on exhalationHyper-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

  • EmphysemaBleb formation

    Risk of pneumothoraxInterior airway pressure

    CO2 RetentionPotential worsening with CPAP

  • ContinuousPositiveAirway Pressure

  • The use of CPAP prehospitally reduces the need for intubation by 30% and reduces mortality by 20%Annals of Emergency Medicine, September 2008

  • CPAPNon-invasive ventilation

    Continuous O2 delivered at a set positive pressure throughout the respiratory cycle

  • Positive PressurePUSHES air into the chestOvercomes airway resistance

    Bag valve maskDemand valveIntubation / mechanical ventilationCPAP

  • Effects of CPAPIncreases functional residual capacity

    Increases alveolar surface area available for gas exchange

    Increases oxygen diffusion across alveolar membranes

    Reduced work of breathing

  • How CPAP WorksMaintains constant level of airway pressure

    Keeps alveoli open (asthma, COPD)

    Moves fluid into vasculature (pulmonary edema)

    Improves gas exchange

    Buys time for medications to work

  • IndicationsSevere Respiratory Distress / Respiratory FailureAccessory 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

  • ContraindicationsRespiratory rate < 10 breaths / minuteSystolic blood pressure < 100 mmHgConfusionInability to understand directions and cooperate with application of CPAPHistory of pneumothoraxHistory of recent tracheo-bronchial surgeryActive nausea or vomitingDespite antiemetic therapy by paramedics

  • LimitationsCPAP is not a mechanical ventilator

    Tight mask seal can create claustrophobic responseConsider allowing patient to self-seal (hold own mask) until initial benefits recognized

    CPAP is powered by on-board oxygen supply

  • Oxygen UtilizationOxygen Demand

  • Summary

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


  • Special ThanksTo:

    Peter Canning for time and effort in initial development of programDavid Bailey for contributions of supplemental information to enhance presentationRichard Sanders for development of glossary of termsNancy Brunet for final project coordination

  • PlaceholderAdd specific manufacturer product information and local concerns

  • PracticalSkillsSession

    *Presenter should briefly review basic function of each component of respiratory tree

    Point out that while diaphragm is outside of the respiratory tree it is a functional unit of the respiratory process

    *Regular contraction and relaxation of diaphragm and intercostal muscles results in negative pressure causing air to be drawn in to lungs

    Hemodynamic EffectsContraction of diaphragm and external intercostal muscles produces negative intrathoracic pressureNegative pressure engorges vena cava increasing cardiac preload

    Relaxation of diaphragm and contraction of intercostal and abdominal muscles produces positive pressurePositive pressure loads blood into the right atrium increasing Left Ventricular filling and cardiac output

    Process of inhalation stops when stretch receptors send signal via vagus nerve that pressure has equalized*In adults the trachea is about 2.5 cm (1 inch) in diameter and the smallest bronchioles are less than 0.5 mm (19 / 1,000th inch) in diameter

    Smooth muscle can constrict decreasing the internal diameter of bronchiole (bronchoconstriction) Br