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CPAP training developed for my department and in review for possible adoption by the state.

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  • 1.State of Idaho CPAP training Module DRAFT

2. Revision Information

  • Developed October 2008
  • Revised November 2008
  • For Further Information Please contact:
    • Instructor contact information

3. Introduction

  • Instructor Introduction
    • Experience
    • Conflicts of interest
  • Device to be used for this training
  • This presentation was developed at the direction of the State of Idaho, Department of Health and Welfare, Bureau of EMS

4. Special Thanks

  • The Men and Women of Ada County Paramedics for their input, advice, and good sportsmanship in developing this presentation
  • www.adaparamedics.com
  • State of Maine EMS
  • State of Wisconsin EMS

5. CPAP - Background

  • Continuous Positive Airway Pressure (CPAP) and related technologies have been in use for since the 1940 in respiratory failure.
  • It has been largely indicatedto assist patients with primary and secondary sleep apnea, and globally this continues to be its largest market.
  • In recent history (1980s) it has found wide acceptance in hospital settings (usually CCU, ICU, and ERs) for patients suffering varying degrees of respiratory failure of a wide variety of origins.
    • Acute Pulmonary Edema (APE) most common

6. CPAP - Background

  • CPAP is anon-invasiveprocedure that is easily applied in the pre-hospital setting.
  • CPAP is an established therapeutic modality, well studied to reduce both mortality and morbidity.
  • CPAP has been shown to be an preferable alternative to intubation in some patients.

7. History of CPAP

  • 1912 - Maintenance of lung expansion during thoracic surgery(S. Brunnel)
  • 1937 - High altitude flying to prevent hypoxemia.(Barach et al)
  • 1967 - CPPB + IPPV to treat ARDS(Ashbaugh et al)
  • 1971 - Term CPAP introduced, used to treat HMD in neonates(Gregory et al)
  • 1972 - CPAP used to treat ARF(Civetta et al)
  • 1973 - CPAP used to treat COPD(Barach et al)
  • 1981 - Downs generator (Fried et al)
  • 1982 - Modern definition of CPAP (Kielty et al)

8. Boussignac CPAP?

  • 1973- Boeing 707 crashed near Paris France
    • 125 fatalities, 3 survivors with severe respiratory trauma
  • CPAP was not well known at the time.
  • Mortality for these injuries was 100%
  • Dr. Georges Boussignac, decided not to intubate these patients but to treat them instead with Non Invasive Ventilation (NIV) and an early form of CPAP.
    • The original CPAP was a bag over the head with constant air flow at greater than atmospheric pressure.

9. Types of CPAP 10. Boussignac 11. Oxypeep 12. Whisperflow Flow Generators 13. Emergent Products PortO2vent 14. CAREvent ALS + CPAP 15. Physiology of CPAP 16. Vital Terminology

  • Tidal Volume (Vt)
  • Minute Volume (Vm)
  • Peak Inspiratory Flow
  • Functional Reserve Capacity (FRC)
  • Inspired Oxygen (FiO2)
  • Work of Breathing (WOB)

17. 18. Airway and Respiratory Anatomy and Physiology

  • Pathway review
  • Oxygenation and Ventilation
  • Functional Residual Capacity
  • Work of breathing

19. Airway and Respiratory Anatomy

  • Pathways-

20. Airway and Respiratory Anatomy

  • Pathways-

21. Question: So why does oxygen pass into the blood? A: The Pressure Gradient!!!! Airway and Respiratory Physiology 22. Airway and Respiratory Physiology

  • The Pressure gradient!
  • Aveolar Air has higher content of OXYGEN than venous (deoxygenated) blood
  • Therefore oxygen transfersfromthe airintothe blood.
  • This is called the Pressure Gradient
    • The higher the inspired oxygen (FiO2) the better the pressure gradient!

23. Airway and Respiratory Physiology

  • Oxygen Saturation Curve

Picture released into public domain by wikipedia 24. Airway and Respiratory PhysiologyFRC

  • Functional reserve Capacity (FRC) is the volume of air in the lungs at the end of a normalpassiveexpiration.
    • approximately 2400 ml in a 70 kg, average-sized male
  • FRC decreases with lying supine, obesity, pregnancy and anaesthesia.
  • Important aim of CPAP is to increasefunctional residual capacity (FRC)
    • By increasing he FRC, the surface area of the Aveoli is distended ( increased ).
    • Greater surface areaimprovesgas exchange (oxygenation and ventilation)
    • This improves Spo2/SaO2

25. Airway and Respiratory Physiology WOB

  • Work of breathing (WOB) is respiratory effort to effect oxygenation and ventilation.
  • Important aim of CPAP is to reducework of breathing (WOB)

26. Airway and Respiratory Physiology WOB

  • Signs of increased WOB:
    • Dyspnea on Exertion (DOE)
    • Speech Dyspnea
    • Tripoding
    • Orthopnea
    • Accessory Muscle Use/Restractions
    • Lung Sounds
      • Doorway Test
      • Silent Chest!!!!

27. Airway and Respiratory Physiology WOB

  • Increased WOB :
  • Respiratory Fatigue
  • Respiratory Distress
  • Respiratory Failure
  • CPAPreducesWOB

28. Airway and Respiratory Pathology 29. Airway and Respiratory Pathology CHF

  • Precipitating Causes
    • Non Compliance with Meds and Diet
    • Acute MI
    • Arrhythmia (e.g. AF)
    • Increased Sodium Diet (Holiday Failure)
    • Pregnancy (PIH, Pre-eclampsia, Eclampsia)

30. Airway and Respiratory Pathology CHF

  • Severe resp distress
  • Foamy blood tinged sputum
  • Accessory muscle use
  • Apprehension, agitation
  • Speech Dyspnea
  • Diaphoresis
  • Bilateral crackles or Rhales
  • Orthopnea (cant lie down)
  • Paroxysmal nocturnal dyspnea (PND)
  • Cyanosis
  • Pedal Edema
  • JVD
  • Chest pain (possible
  • co-existent AMI)
  • abnormal vitals (increased B/P; rapid pulse; rapid & labored respirations

31. Cardiac Asthma?

  • Fluid leaks into the Interstitial Space
    • Airways narrow
    • Mimics broncoconstriction seen in asthma
      • May actually exacerbate asthma if a co-existing PMHx
    • Produces Wheezing

32. Infiltration of Interstitial Space

  • Normal
  • Micro-anatomy
  • Micro-anatomy with fluid movement.

33. Airway and Respiratory Pathology CHF

  • The following treatments should be done concurrently with CPAP, patient condition permitting*.
  • High Flow Oxygen!!!
  • Nitroglycerin *
    • 0.4 mg sl every 5 minutes;
    • 0.5-2 inches transdermal
    • 5-200 mcg/min IV Drip
  • Lasix *
    • 20- 80 mg IV/IM (or double daily dose if already on Lasix)
  • Opiates*
    • Reduce Anxiety
    • Mild Vasodilator
    • 2.5-5 mg q5 minutes IVP
  • (* = defer to local protocol or medical control)

34. Airway and Respiratory Pathology Asthma and COPD

  • Obstructive vs Reactive airways
  • Bronchoconstrictive issues
  • Poor Gas Exchange
  • Accessory Muscle Use/Muscle Tiring
  • CPAP is best reserved for those patients who are refractory to normal interventions, and have a severe presentation.
    • At least TWO doses of bronchedialtorsshouldbe administered before the provider initiates CPAP.

35. Airway and Respiratory Pathology Asthma and COPD

  • The following treatments should be done concurrently with CPAP, patient condition permitting*.
  • High Flow Oxygen!!!
  • Bronchodilators*
      • Albuterol 2.5 mg (0.83% in 3 cc)/ Atrovent 0.5 mg (0.02% in 2.5 cc) nebulized.
      • Repeat as needed with Albuterol Onl