CPAP in Loudoun

Pulmodyne O2-RESQ™

CPAP System

What is CPAP?

• Continuous positive airway pressure

• Provides respiratory support

• Improves gas exchange and vital signs

• Decreases work of breathing and dyspnea

• Decreases need for intubation in CHF and acute pulmonary edema

Key Points

• Effective adjunct in the management of

pulmonary edema

• Buys time for administered medications to take

effect

CPAP vs. Intubation

CPAP

• Non-invasive

• Easily discontinued

• Easily adjusted

• Simple training

• Does not require

sedation (anxiolytics

optional)

• Relatively comfortable

Intubation

• Invasive

• Usually don’t extubate in

field

• Potential for infection

• Requires highly trained

personnel

• Requires sedation (for

CHF/pulmonary edema)

• Traumatic

Lung Inflation

CPAP works by

providing increased

continuous gas

pressures at the level

of the lower airway

structures, improving

gas exchange in the

alveoli

Low tidal volumes

ventilate upper zone

Moderate tidal volumes

ventilate middle zone

High tidal volumes

ventilate lower zone

Mechanism

• CPAP increases the airway pressures allowing

for better gas diffusion & for re-expansion of

collapsed alveoli

• CPAP allows the refilling

of collapsed, airless

alveoli

• CPAP expands the

surface area of the collapsed alveoli allowing

more surface area to be in contact with

capillaries for gas exchange

How?

• Constant and continuous positive pressure

• Minimal fluctuations between inspiration and

expiration

– More dramatic fluctuations = BiPAP

• Constant pressure reduces resistance to

airflow

– Decreases work of breathing

Therapeutic Goals

• Increase the amount of inspired oxygen

• Increase the amount of that oxygen that is moved into the circulatory system

• Decrease the work of breathing

• In turn to:

– Decrease the need for intubation

– Decrease the hospital stay

– Decrease the mortality rate

Loudoun County Protocols Visit them at www.loudoun.gov/fire

• Everyone knows to consider in COPD/Asthma.

– COPD/asthma refractory to steroids and

nebulizer: 5 cm H2O setting

– Unless it’s bad….

• Do you remember…

Dr. Morgan allows CPAP (along with Epi and Mag++) to

be requested sooner via Medical Control

(you can request to do all three simultaneously)

Loudoun County Protocols Visit them at www.loudoun.gov/fire

• Everyone knows to consider CPAP in CHF

– CHF/pulmonary edema w/ accessory muscle use, RR > 24, and/or SpO2 < 90%: 10 cm H2O setting

• Do you remember…

– CPAP can take priority over meds and even the IV

– When using both CPAP and NTG, if the patient improves – discontinue the NTG

– Be alert for decreasing mental status and bradycardia… you are about to get really busy…

Loudoun County Protocols Visit them at www.loudoun.gov/fire

• Everyone knows to consider CPAP in Smoke

Inhalation and Carbon Monoxide Poisoning.

Right?

Moderate to severe cases – use 5cm H2O setting

Increasing the oxygen pressure to force more CO off

the hemoglobin. Use the RAD57

Contraindications

• Respiratory or cardiac arrest

• Systolic BP < 90 mm Hg

• Severely depressed level of consciousness

• Inability to maintain airway patency

• Major trauma

• Vomiting

• Pneumothorax

• Gastric distention

Coaching the Patient

• Success depends upon patient tolerance

• You must thoroughly explain the procedure

• Anticipate and control anxiety (one can request pharmacological assistance)

• Verbally coach breathing

• Consider having the patient hold the mask in

place prior to securing

• Attach head straps loosely and gradually

tighten

Change is coming!

• Moving away from the Whisperflo to another

system

• Piloting new system now

– Early results are looking very good

Why the change?

• Providers identified several aspects of the

Whisperflo that they did not like.

– Tubing too short

– Poor understanding of the control mechanism

– Too complex a setup for assisting BLS personnel

– ~15 total time to deplete a cylinder (reported)

– Mask fit was poor or broke easily

– Too much “stuff”, requiring a separate bag.

We listened.

• Searched for a simple to use system that integrated easily into our current practices

• Less “stuff” - potentially fits in O2 or house kit

• Easy set-up, easy clean up

• Cheaper

• Easy in-line neb now possible

• Did we mention cheaper?

The O2-RESQ™ System

High Flow Generator

• Fixed flow Venturi

device

• Oxygen supply with

entrained air

– Venturi tube ratio of 10:1

– Flow up to 140 L/min

total, 30% FiO2

• Built-in air filter

• Connects to 50 psi

oxygen source with

DISS connector

Portable Oxygen Source

• 50 psi DISS port

on portable

• Leave flow set to

zero

• Full D cylinder =

~28 minutes of

pressure at 10

cm H2O

On-Board Oxygen Source

Setup depends on the flow meter

Two types

– Fixed tubing connection (metal attachment) • Cannot be used for CPAP

• Must use segment of old CPAP system! – Remove the flow meter

– Attach the Ohio-style connector from the old CPAP system

– Screw the CPAP to the DISS connector.

– Removable Connector • Commonly called the ‘christmas tree’

• When removed, exposed the DISS threads

Direct Connection to On Board Oxygen • Ohio connector

• Remove High Pressure line

• Screw CPAP to exposed DISS

threads

Removable Connector

• Unscrew connector/

adapter

• Screw CPAP onto

exposed DISS threads

• Set to 25 LPM

– Some regulators max out

at 15 lpm – This is

acceptable, but be

prepared to provide

supplemental oxygen

Extendable Tubing: 5 ft

(yes, it really is long enough

Adjustable CPAP Valve

• Variable pressure at any

flow rate

– Twist to set pressure

– 5, 7.5, 10 cm H2O

• Built-in anti-asphyxiation

valve (orange)

Air Flow

Anti-Asphyxiation Valve

• Ensure that valve covers anti-asphyxiation

port during inspiration!

BiTrac ED™ Mask and Head Strap

• Multi-positioning (up/down, in/out) OmniClip™ with silicone forehead pad

• Dual lip silicone cushion for low-pressure seal

• Medium and large sizes in field

• Head strap – Velcros around

OmniClip™

– Clips to mask

– Four adjustment points

Patient Setup

• Choose appropriate mask size

• Attach generator to oxygen source and turn on

• Attach CPAP valve to tubing and mask

• Place mask on patient

• Attach head strap clips and adjust

• Check anti-asphyxiation valve

• Readjust as necessary

Choose the

appropriate

mask size

Connect the tubing,

CPAP valve, and mask

Set PEEP then,

Connect to the

oxygen source and

turn on

Place the mask on

the patient

Attach head strap

clips

Adjust the

head straps

as necessary

Check the anti-

asphyxiation valve

Readjust as necessary

Nebulizer

• T-adapter is not included

in CPAP kit (stocked

separately)

• Two pieces required

– Spring-loaded nebulizer

T-adapter with seal cap

– Size adapter (22 mm

male to 30 mm female)

Can use normal neb with precautions

T-Adapter

• Spring-loaded internal

cap is automatically

lifted by nebulizer

medication chamber

• Does not provide an

airtight seal

– Cover open (bottom) port

when nebulizer not in

use to ensure that air

does not escape

• Regular Neb’s t-adapter does not

prevent pressure loss

• Remove ‘T’ after neb is done

Supplemental Oxygen

• Generator does not

have adjustable flow or

oxygen (FiO2)!

• Two supplemental O2

ports provide access to

provide access for

additional oxygen

– Use oxygen tubing

– Be cognizant of oxygen

supply levels (use a

separate tank if possible)

Important Reminders

• CPAP will exhaust a FULL tank in 28 minutes

– Plan accordingly. Factor in the time it will take to move a

patient with MANY cords, lines and stuff down stairs and

out of the house. If necessary, alter treatment priorities

(within reason) to get to on-board oxygen quickly.

– Using the same tank to run a neb or supplement the FiO2

will deplete the tank even faster. • This is not saying to avoid using the same tank, just factor in the

significantly more rapid depletion of oxygen supply

Important Reminders

• CPAP has priority over IV Access in the

presence of severe distress

• Versed is available via Medical Control to

assist the anxious patient with tolerating the

mask/system.

– Providers must employ caution when using

Versed as it may depress the already overworked

respiratory system

Important Reminders

• Using Capnography may be unreliable as the

positive airflow washes the CO2 away.

• Call for manpower as soon as you think CPAP

will be used

• Replacements are bought by the EMS Council

and obtained from Fire Rescue Logistics

Questions

ASPCA Certified. No animals or Training Officers

were injured in the making of this production.