Pre-Hospital CPAPPre-Hospital CPAP

What the EMS Medical What the EMS Medical Director should knowDirector should know

Keith Wesley, MDKeith Wesley, MD

Wisconsin State EMS Medical DirectorWisconsin State EMS Medical Director

drwesley@charter.netdrwesley@charter.net

ObjectivesObjectives

Review the goal & physiology of CPAPReview the goal & physiology of CPAP

Discuss the indications and Discuss the indications and contraindications for CPAP usecontraindications for CPAP use

Review the literature supporting CPAP useReview the literature supporting CPAP use

Explore the role of CPAP use by pre-Explore the role of CPAP use by pre-hospital providershospital providers

Discuss the methods for implementing Discuss the methods for implementing pre-hospital CPAPpre-hospital CPAP

The Goal of CPAP?The Goal of CPAP?

Reduce the need for pre-Reduce the need for pre-hospital intubation!hospital intubation!

CPAP vs. IntubationCPAP vs. Intubation

CPAP

Non-invasive

Easily discontinued

Easily adjusted

Use by EMT-B

Minimal complications

Does not require sedation

Comfortable

IntubationIntubation

Invasive

Intubated stays intubated

Requires highly trained personnel

Significant complications

Can require sedation or RSI

Potential for infection

The ProblemThe Problem

Congestive Heart FailureCongestive Heart Failure– Incidence 10 per 1000 patient (over age 65) transportsIncidence 10 per 1000 patient (over age 65) transports– 25% of Medicare Admissions25% of Medicare Admissions– Average LOS is 6.7 daysAverage LOS is 6.7 days– 6.5 million hospital days6.5 million hospital days– Those who get intubated have significantly longer LOSThose who get intubated have significantly longer LOS– 33% get intubated without non-invasive pressure 33% get intubated without non-invasive pressure

supportsupport– Intubated patients have 4 times the mortality of non-Intubated patients have 4 times the mortality of non-

intubated patientsintubated patients

The ProblemThe Problem

CHF/Pulmonary EdemaCHF/Pulmonary Edema– Interstitial fluid interferes with gas exchange Interstitial fluid interferes with gas exchange

(ventilation and oxygenation)(ventilation and oxygenation)– Increased myocardial workload resulting in Increased myocardial workload resulting in

higher oxygen demands (many of these higher oxygen demands (many of these patients are suffering ischemic heart disease)patients are suffering ischemic heart disease)

– Traditional therapies designed to reduce pre-Traditional therapies designed to reduce pre-load and after-load as well as remove load and after-load as well as remove interstitial fluidinterstitial fluid

The ProblemThe Problem

COPD/AsthmaCOPD/Asthma– Increased work of breathingIncreased work of breathing– Hypercarbic (ventilation issue)Hypercarbic (ventilation issue)– Traditional therapies involve brochodilators Traditional therapies involve brochodilators

which require adequate ventilationwhich require adequate ventilation– Higher mortality rate if intubatedHigher mortality rate if intubated– Difficult to wean once intubatedDifficult to wean once intubated– Extremely difficult patient to intubate in the Extremely difficult patient to intubate in the

pre-hospital arena – usually requires RSIpre-hospital arena – usually requires RSI

Physiology of CPAPPhysiology of CPAP

Airway pressure maintained at set level throughout inspiration and expiration

Maintains patency of small airways and alveoli

Improves gas exchange

Improves delivery of bronchodilators

Moves extracellular fluid into vasculature

Reduces work of breathing

Supporting LiteratureSupporting Literature

JAMA December 28, 2005 “Noninvasive JAMA December 28, 2005 “Noninvasive Ventilation in Acute Cardiogenic Edema”, Ventilation in Acute Cardiogenic Edema”, Massip et. al.Massip et. al.– Meta-analysis of studies with good to Meta-analysis of studies with good to

excellent dataexcellent data– 45% reduction in mortality45% reduction in mortality– 60% reduction in need to intubate60% reduction in need to intubate

Supporting LiteratureSupporting Literature

Reviews in Cardiovascular Medicine, vol. 3 supl. 4 2002, Reviews in Cardiovascular Medicine, vol. 3 supl. 4 2002, “Role of Noninvasive Ventilation in the Management of “Role of Noninvasive Ventilation in the Management of Acutely Decompensated Heart Failure”Acutely Decompensated Heart Failure”

““Though BLPAP has theoretical advantages over CPAP, Though BLPAP has theoretical advantages over CPAP, there are questions regarding its safety in a setting of there are questions regarding its safety in a setting of CHF. The Key to success in using NIV to treat severe CHF. The Key to success in using NIV to treat severe CHF is proper patient selection, close patient monitoring, CHF is proper patient selection, close patient monitoring, proper application of the technology, and objective proper application of the technology, and objective therapeutic goals. When used appropriately, NIV can be therapeutic goals. When used appropriately, NIV can be a useful adjunct in the treatment of a subset of patients a useful adjunct in the treatment of a subset of patients with acute CHF at risk for endotracheal intubation.”with acute CHF at risk for endotracheal intubation.”

Supporting LiteratureSupporting Literature

Brochard (French abstract) “ Noninvasive Brochard (French abstract) “ Noninvasive ventilation for acute exacerbations of ventilation for acute exacerbations of COPD”COPD”

“…“…can reduce the need for intubation, LOS can reduce the need for intubation, LOS in hospital, and mortality rate”in hospital, and mortality rate”

BiPAP vs CPAPBiPAP vs CPAP

European Respiratory Journal, vol. 15 European Respiratory Journal, vol. 15 2000 “Effects of biphasic positive airway 2000 “Effects of biphasic positive airway pressure in patients with chronic pressure in patients with chronic obstructive lung disease”obstructive lung disease”– BiPAP resulted in overall BiPAP resulted in overall higherhigher intrathoracic intrathoracic

pressures – reduces myocardial perfusionpressures – reduces myocardial perfusion– BiPAP resulted in BiPAP resulted in lowerlower tidal volumes tidal volumes– BiPAP resulted in BiPAP resulted in higherhigher WOB WOB

Pre-hospital CPAPPre-hospital CPAP

PEC 2000 NAEMSP Abstract, “Pre-hospital use of CPAP PEC 2000 NAEMSP Abstract, “Pre-hospital use of CPAP for presumed pulmonary edema: a preliminary case for presumed pulmonary edema: a preliminary case series”, Kosowsky, et. al. series”, Kosowsky, et. al. 19 patients19 patientsMean duration of therapy 15.5 minutesMean duration of therapy 15.5 minutesOxygen sat. rose from 83.3% to 95.4%Oxygen sat. rose from 83.3% to 95.4%None were intubated in the fieldNone were intubated in the field2 intubated in the ED2 intubated in the ED5 subsequently intubated in hospital5 subsequently intubated in hospital““Pre-hospital CPAP is feasible and may avert the need Pre-hospital CPAP is feasible and may avert the need for intubation”for intubation”

UTMB ExperienceUTMB Experience

Dr. Jeffery Miller – UT GalvestonDr. Jeffery Miller – UT GalvestonIRB approval through UTMBIRB approval through UTMB6 hours didactic instruction6 hours didactic instructionRecognize CHF – trial limited to CHFRecognize CHF – trial limited to CHF– Differentiate CHF, COPD, Asthma & Differentiate CHF, COPD, Asthma &

BronchitisBronchitis– 2 hours clinical training2 hours clinical training

Instruction on assessment most important Instruction on assessment most important reason for successreason for success

UTMB ExperienceUTMB Experience

Data Summary Sept. 1996 – May 1997Data Summary Sept. 1996 – May 1997 Total intubations 22Total intubations 22 Hospital stay 14.8 daysHospital stay 14.8 days ICU admission 100%ICU admission 100%

Data Summary Sept. 1997 – May 1998Data Summary Sept. 1997 – May 1998 CPAP 50CPAP 50 Total intubations 8 (15%)Total intubations 8 (15%) CPAP failures 4 (8%)CPAP failures 4 (8%) Hospital stay 8 daysHospital stay 8 days ICU admission 48%ICU admission 48%

Wisconsin EMT–Basic ExperienceWisconsin EMT–Basic Experience

Question: Can EMT-Basics apply CPAP Question: Can EMT-Basics apply CPAP as safely as Paramedics?as safely as Paramedics?

50 EMT-Basic services50 EMT-Basic services

2 hour didactic, 2 hour lab, written and 2 hour didactic, 2 hour lab, written and practical testpractical test

Required data collectionRequired data collection

Compared to same data collected by ALS Compared to same data collected by ALS services during same periodservices during same period

Wisconsin EMT–Basic ExperienceWisconsin EMT–Basic Experience

Required data collectionRequired data collection– Criteria used to apply CPAPCriteria used to apply CPAP– Absence of contraindicationsAbsence of contraindications– Q 5 min. vital signs including oxygen sats.Q 5 min. vital signs including oxygen sats.– Subjective dyspnea scoreSubjective dyspnea score

Because EMT–Basics don’t diagnose a Because EMT–Basics don’t diagnose a unique “Respiratory Distress” protocol unique “Respiratory Distress” protocol used to capture patientsused to capture patients

Adult Respiratory Distress Protocol(Age greater than 12)

Routine Medical Assessment

Oxygen2 LPM via Nasal Cannula

Titrate to maintain Pulse ox of >92%

Is Patient a candidate for Mask CPAP?-Respiratory Rate > 25 / min

-Retractions or accessory muscle use-Pulse ox < 94% at any time

See Mask CPAP Protocol

No

Yes

No

No

Is the Patient wheezing and/or doesthe Patient have a history of Asthma/COPD?

Does the Patient have rales and/or does the Patient have a history of congestive heart

failure (CHF)?

YesAdminister Albuterol / Atrovent by Nebulizer

If Basic IV Tech: Administer 1 spray

sublingual NTG every5 minutes as long as

systolic BP is greater than 100mmHg

Yes

Contact Medical ControlConsider ALS Intercept and Transport

Asses Patient, record vital signsand pulse ox before applying oxygen

Does the Patient meet two or moreInclusion Criteria?

No

Yes

Does the Patient meet anyExclusion Criteria?

Continue standard BLSRespiratory Distress Protocol

Administer CPAP5 cm H2O of pressure AND

Reassess patient, vital signs, andrespiratory distress scale every 5 min.

Notify Medical ControlConsider ALS Intercept

and continue BLSRespiratory Distress Protocol

Patient condition is stableor improving

Continue CPAPReassess patient every

5 minutes

Patient condition is deterioratingDecreasing LOC

Decreasing Pulse Ox

Notify Medical Control

Remove CPAPApply BVM Ventilation

Mask CPAP for EMT-Basic

CPAP Inclusion Criteria(2 or more of the following)

-Retractions or Accessory muscle use-Respiratory Rate > 25 / minutes

-Pulse Ox < 94% at any time

CPAP Exclusion Criteria-Unable to follow commands

-Apnea-Vomiting or active GI bleed

-Major trauma / pneumothorax

Conditions Indicated for CPAPCongestive Heart Failure

COPD / AsthmaPneumonia

Yes

No

Complete CPAP Data Form and submit to service Medical Director for each patient placed on CPAP

Wisconsin EMT-Basic ExperienceWisconsin EMT-Basic Experience

Results (preliminary – study completed Results (preliminary – study completed 11/05)11/05) 500 applications of CPAP (114 services)500 applications of CPAP (114 services) 99% met criteria for CPAP on review of medical 99% met criteria for CPAP on review of medical

directordirector No field intubations by those services with ALS No field intubations by those services with ALS

interceptsintercepts No significant complicationsNo significant complications All oxygen sats. improved, dyspnea reduced by All oxygen sats. improved, dyspnea reduced by

average of 50%average of 50%

Wisconsin EMT – Basic ExperienceWisconsin EMT – Basic Experience

State approved CPAP for EMT-Basic State approved CPAP for EMT-Basic scope of practice 2/06scope of practice 2/06

Questions yet to be answeredQuestions yet to be answered– What conditions did the patients have?What conditions did the patients have?– Was it applied too liberally?Was it applied too liberally?

Key PointKey Point– Services without ALS intercept did just as well Services without ALS intercept did just as well

as those with itas those with it

Eau Claire Fire ExperienceEau Claire Fire Experience

Paramedic serviceParamedic service

July 2003 – June 2004July 2003 – June 2004

Measured end-tidal CO2, oxygen sats., Measured end-tidal CO2, oxygen sats., and subjective dyspnea scoreand subjective dyspnea score

COPD/Asthma – Continuous nebsCOPD/Asthma – Continuous nebs

CHF – Nitro infusion or repeated spraysCHF – Nitro infusion or repeated sprays

Eau Claire Fire ExperienceEau Claire Fire Experience

50 applications50 applications

No field intubationsNo field intubations

Initial CO2 levels average 62Initial CO2 levels average 62

All patients CO2 levels increased during All patients CO2 levels increased during first 5 minutesfirst 5 minutes

CO2 levels increasing more than 10 CO2 levels increasing more than 10 positively predicted CPAP failurepositively predicted CPAP failure

Indications for CPAPIndications for CPAP

CHFCHF

Pulmonary EdemaPulmonary Edema– Near DrowningNear Drowning– Inhalation ExposureInhalation Exposure

COPDCOPD

AsthmaAsthma

PneumoniaPneumonia

Items to ConsiderItems to Consider

How good is current care for respiratory How good is current care for respiratory distress?distress?– Aggressive nitrates for CHF?Aggressive nitrates for CHF?– Aggressive use of bronchodilators?Aggressive use of bronchodilators?– Pre-hospital and hospital intubation rate?Pre-hospital and hospital intubation rate?

Requires active medical oversightRequires active medical oversight– Airway management is a sentinel eventAirway management is a sentinel event

ALS or BLS or BOTH?ALS or BLS or BOTH?

Items to ConsiderItems to Consider

EquipmentEquipment– Must be easy to use and portableMust be easy to use and portable– Adjustable to patient’s needAdjustable to patient’s need– Easily started and discontinuedEasily started and discontinued– Provide quantifiable and reliable airway Provide quantifiable and reliable airway

pressurespressures– Conservative oxygen utilizationConservative oxygen utilization– Not interfere with administration traditional Not interfere with administration traditional

therapies for underlying conditiontherapies for underlying condition

Items to ConsiderItems to Consider

Oxygen concentrationOxygen concentration– Fixed versus Variable ratesFixed versus Variable rates

Fixed rates are either 35% or 100% in current Fixed rates are either 35% or 100% in current models but actual concentration will be less models but actual concentration will be less depending on leaks and minute ventilationdepending on leaks and minute ventilation

Variable rate increases chance of inadequate Variable rate increases chance of inadequate oxygen supplyoxygen supply

– Pressure levelPressure levelMost studies show 5cm H20 sufficientMost studies show 5cm H20 sufficient

Complication rate goes up with pressureComplication rate goes up with pressure

SummarySummary

CPAP is a non-invasive procedure that is easily applied and can be easily discontinued without untoward patient discomfort

CPAP is an established therapeutic modality

Data supports its use in CHF, pulmonary edema, COPD/Asthma, and pneumonia

Questions?Questions?