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  • 1. Continuous Positive Airway Pressure (CPAP) Washington State Department of Health EMT Basic Curriculum Developed by: Lynn Wittwer, MD, MPD Marc Muhr, EMT-P TJ Bishop, EMT-P Clark County EMS Keith Wesley, MD, EMS Medical Director State of Wisconsin

2. Washington EMT-B CPAP Curriculum 2 CPAP Curriculum EMT Basic Introduction Review of Anatomy and Physiology CPAP Overview Pulse Oximetry Review of Respiratory Distress Treatment With CPAP 3. Washington EMT-B CPAP Curriculum 3 What is CPAP? Continuous Positive Airway Pressure (CPAP) A non-invasive alternative to intubation Does not require any sedation It provides comfort to the patient with acute respiratory distress by reducing work of breathing 4. Washington EMT-B CPAP Curriculum 4 Why CPAP? Respiratory Distress is a common reason why people call 911! Established therapeutic alternative Easily applied, easily discontinued 5. Washington EMT-B CPAP Curriculum 5 Key Points of CPAP CPAP has been successfully demonstrated as an effective adjunct in the management of a variety of respiratory distress states. CPAP may prove to be a viable alternative in many patients previously requiring endotracheal intubation by prehospital personnel. 6. Washington EMT-B CPAP Curriculum 6 CPAP vs. Intubation CPAP Non-invasive Easily discontinued Easily adjusted Use by EMT-B Does not require sedation Comfortable Intubation Invasive Usually dont extubate in field Potential for infection Requires highly trained personnel Can require sedation Traumatic 7. Review of Anatomy & Physiology 8. Washington EMT-B CPAP Curriculum 8 Elements of the Airway UPPER AIRWAY Nares Nasopharynx Oropharynx Tongue Epiglottis/Glottis Vocal Cords LOWER AIRWAY Trachea/Esophagus Carina Main stem Bronchi Secondary Bronchi Bronchioles Alveoli 9. Washington EMT-B CPAP Curriculum 9 Upper Airway 10. Washington EMT-B CPAP Curriculum 10 Pharynx Nasopharynx Uppermost portion of airway, just behind nasal cavities Nasal septum Vestibule Olfactory membranes Sinuses Oropharynx Begins at the level of the uvula and extends down to the epiglottis Opens into the oral cavity 11. Washington EMT-B CPAP Curriculum 11 Larynx Three main functions: Air passageway between the pharynx and lungs Prevents solids and liquids from entering the respiratory tree Involved in speech production 12. Washington EMT-B CPAP Curriculum 12 Larynx An outer casing of nine cartilages Thyroid cartilage Cricoid cartilage Only complete cartilaginous ring in the larynx Epiglottis Hyoid bone Cricothyroid membrane Vocal cords 13. Washington EMT-B CPAP Curriculum 13 Lower Airway 14. Washington EMT-B CPAP Curriculum 14 15. Washington EMT-B CPAP Curriculum 15 Lungs Principal function is respiration Attached to heart by pulmonary arteries and veins Separated by mediastinum and its contents Base of each lung rests on the diaphragm Apex extends 2.5 cm above each clavicle 16. Washington EMT-B CPAP Curriculum 16 Pleural Cavity A separate pleural cavity surrounds each lung Two layers (visceral and parietal) Pleural space 17. Washington EMT-B CPAP Curriculum 17 Respiratory System - Physiology The respiratory system functions as a gas exchange system Oxygen is diffused into the bloodstream for use in cellular metabolism 18. Washington EMT-B CPAP Curriculum 18 Respiratory System - Physiology Wastes, including carbon dioxide, are excreted from the body via the respiratory system 19. Washington EMT-B CPAP Curriculum 19 Ventilation Ventilation refers to the process of air movement in and out of the lungs The volume of air moved in each breath is the tidal volume The volume still remaining in the chest after exhalation is the functional reserve capacity. FRC 20. Washington EMT-B CPAP Curriculum 20 Inspiration and Expiration Inspiration Chest wall expands Lung space increases Pressure gradient causes gas to flow into the lungs Expiration Chest wall relaxes Elastic recoil causes thorax and lung space to decrease in size Pressure gradient created in thoracic cavity causes air to move out of the chest 21. Washington EMT-B CPAP Curriculum 21 Pressure Changes During Inspiration and Expiration 22. Washington EMT-B CPAP Curriculum 22 Mechanics of Breathing 23. Washington EMT-B CPAP Curriculum 23 Mechanics of Respiration 24. Washington EMT-B CPAP Curriculum 24 Ventilation The following must be intact for ventilation to occur: Neurologic control to initiate ventilation Nerves between the brainstem and the muscles of respiration Functional diaphragm and intercostal muscles A patent upper airway A functional lower airway Alveoli that are functional and not collapsed 25. Washington EMT-B CPAP Curriculum 25 Diffusion In order for diffusion to occur, the following must be intact: Alveolar and capillary walls that are not thickened Interstitial space between the alveoli and capillary wall that is not enlarged or filled with fluid 26. Washington EMT-B CPAP Curriculum 26 How does CPAP work Splints the upper airway preventing collapse Uses continuous oxygen flow with pressure to push air into the lungs and push the fluid into the bloodsteam Recruits alveoli that have collapsed 27. Washington EMT-B CPAP Curriculum 27 CPAP Mechanism Increases pressure within airway. Airways at risk for collapse from excess fluid are stented open. Gas exchange is maintained Increased work of breathing is minimized 28. Washington EMT-B CPAP Curriculum 28 Pulse Oximetry Basic concept of Pulse Oximetry monitoring. Objectively determines oxygenation status when applied correctly. Measures the hemoglobin saturation in the bloodstream via red and infrared light, through the skin to the arterial bed. 29. Washington EMT-B CPAP Curriculum 29 Pulse Oximetry Possible invalid readings Low blood flow states, (i.e., shock states, hypothermic, hypovolemia) may show an inaccurate low oxygenation percent. Carbon monoxide poisoning may show a false high percent reading. Anemias and oxygen capacity carrying diseases (i.e., sickle cell) may also show a false high reading. Fingernail polish, excessive grease and dirt, nail-tips, or gel nails may cause a false low reading. 30. Review of Respiratory Distress 31. Washington EMT-B CPAP Curriculum 31 Respiratory Distress Work of Breathing Respiratory rate greater than 25/minute The presence of retractions and/or use of accessory muscles Appearance = Mental Status Pulse Oximetry < 94% Effects of hypoxia and hypercarbia indistinguishable Circulation/Skin Color Severe cyanosis Pallor and diaphoresis 32. Washington EMT-B CPAP Curriculum 32 Focused History and Physical Ascertain the patients chief complaint that may include: Dyspnea Chest pain Cough Productive Non-productive Hemoptysis Wheezing Signs of infection Fever, chills Increased sputum production 33. Washington EMT-B CPAP Curriculum 33 History Previous experiences with similar/identical symptoms Known pulmonary diagnosis Medication history Current medications Medication allergies Pulmonary medications Cardiac-related drugs History of the present episode Exposure and smoking history 34. Washington EMT-B CPAP Curriculum 34 Pulmonary Edema Congestive Heart Failure Defined Fluid which collects in the lung tissue and alveoli Signs/Symptoms/Assessment Anxious, Pale, Clammy, Dyspnea, Tachypnea, Confusion, Edema, Hypertension, Diaphoretic Rales, Ronchi, Tachycardia, JVD, Pink Frothy Sputum, Cyanosis 35. Washington EMT-B CPAP Curriculum 35 Pulmonary Edema Congestive Heart Failure Signs/Symptoms/Assessment Fatigue Nocturia Dyspnea on exertion Paroxysmal nocturnal dyspnea Chest Pain Orthopnea 36. Washington EMT-B CPAP Curriculum 36 Pulmonary Edema Congestive Heart Failure Treatment Focused history and physical exam Complains of trouble breathing. Airway control w/ adequate ventilation Oxygenation Has a prescribed nitroglycerine available. Consult medical direction. Facilitate administration of nitroglycerine Baseline vital signs. Reassess 37. Washington EMT-B CPAP Curriculum 37 Chronic Obstructive Pulmonary Disease (COPD) Defined Lung tissue loses elasticity secondary to destruction of the alveoli (Emphysema) Inflammation of the bronchial tree. Diagnosed by productive cough which lasts at least three months a year for at least two consecutive years (Chronic Bronchitis) Any COPD patient may have both 38. Washington EMT-B CPAP Curriculum 38 Chronic Obstructive Pulmonary Disease (COPD) Signs/Symptoms/Assessment Exertional dyspnea Productive cough/wheezing Minor hemoptysis Tachypnea/exertional muscle use Pursed lip exhalation May have coarse crackles Accessory muscle use Hyperexpansion of the thorax (diminished breath sounds) Excessive caloric expenditure 39. Washington EMT-B CPAP Curriculum 39 Chronic Obstructive Pulmonary Disease (COPD) Signs/Symptoms/Assessment Tachypnea, cyanosis, agitation, tachycardia, hypertension Confusion, tremor, stupor, apnea 40. Washington EMT-B CPAP Curriculum 40 Chronic Obstructive Pulmonary Disease (COPD) Treatment Focused history and physical exam Complains of trouble breathing. Airway control w/ adequate ventilation Oxygenation Has a prescribed inhaler available. Consult medical direction. Facilitate administration of inhaler Repeat as indicated. Baseline vital signs. Reassess 41. Washington EMT-B CPAP Curriculum 41 Asthma Defined Condition which causes the bronchi to constrict making it difficult to exhale (air trapping) May be caused by allergic reactions and/or emotional distress The most serious form, status asthmaticus, is a true life-threatening emergency 42. Washington EMT-B CPAP Curriculum 42 Asthma Signs/Symptoms/Assessment Dyspnea, chest tightness, wheezing, and cough Obvious SOB, wheezing, accessory muscle use, paradoxical respirations, hyperresonance, prolonged expiration Change in Mental Status: agitation, confu