Transcript C P A P Continuous Positive Airway Pressure

Continuous Positive
Airway Pressure (CPAP)
Training Module
Nassau County
Regional Emergency Medical
Services Council
Continuous Positive Airway
Pressure (CPAP)
CPAP
Current ALS Adult Protocols have CPAP as a treatment
modality
Nassau County ALS Adult Treatment Protocol 3A, 3A-1,
3I, 3J and 3K
NY State has CPAP as a BLS treatment modality in the BLS
protocols BUT requires your medical director’s, Nassau REMAC
and NY State Bureau of EMS approval
•Non-invasive means of providing respiratory
support for patients who:
•need more than supplemental oxygen but do
not yet require intubation.
•Has been shown to decrease or delay the
need for intubation both in the hospital
and in the field.
RESPIRATORY ANATOMY & PHYSIOLOGY
NOSE
NASAL AIR PASSAGES
MOUTH
PHARYNX
GLOTTIS
TRACHEA
BRONCHI
BRONCHIOLES &
ALVEOLI
PRESSURE CHANGES
MUSCLES OF RESPIRATION
LUNG VOLUMES & CAPACITIES
EXCHANGE & TRANSPORT OF GASES
RESPIRATORY ASSESSMENT
LOOK
LISTEN
FEEL
SIGNS OF RESPIRATORY FAILURE
LOOK:
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ANXIOUS OR COMATOSE
ABSENT, MINIMAL OR UNEVEN CHEST RISE
CYANOSIS
ABDOMINAL BREATHING
BREATHING RATE TOO RAPID OR TOO SLOW
RETRACTIONS
NASAL FLARING
SIGNS OF RESPIRATORY FAILURE
LISTEN:
• GURGLING, STRIDOR, CROWING, SNORING
• WHEEZING
• SPEAKS IN SHORT SENTENCES
• MAY BE UNABLE TO SPEAK
SIGNS OF RESPIRATORY FAILURE
FEEL:
DIAPHORETIC
DIMINISHED OR ABSENT AIR MOVEMENT
DISEASE PROCESSES & CONDITIONS
WHERE CPAP IS INDICATED
•CONGESTIVE HEART FAILURE (CHF)
•PULMONARY EDEMA
•COPD
•ASTHMA
INDICATIONS FOR CPAP USE
PATIENTS OVER 10 YEARS OF AGE PRESENTING IN ACUTE
RESPIRATORY DISTRESS WHO ARE ABLE TO FOLLOW
COMMANDS AND MAINTAIN A PATENT AIRWAY WHO
DISPLAY FINDING OF THE FOLLOWING CONDITIONS:
CHF - PULMONARY EDEMA – ASTHMA/COPD SUBMERSION – DROWNING – SMOKE INHALATION
AND
INDICATIONS FOR CPAP USE
PATIENT MUST MEET TWO OR MORE OF THE
FOLLOWING CRITERIA:
• RESPIRATORY RATE GREATER THAN 24/MINUTE
•NOTABLE INCREASED WORK OF BREATHING
•SpO2 LESS THAN 92% AT ANY TIME
• SKIN MOTTLING, PALLOR, OR CYANOSIS SUGGESTING HYPOXIA
• PRESENCE OF ABNORMAL BREATH SOUNDS OR FROTHY SPUTUM
CONTRAINDICATIONS FOR CPAP USE
•PATIENTS LESS THAN 10 YEARS OF AGE
•UNCONSCIOUSNESS OR GCS LESS THAN 14
•SYSTOLIC BLOOD PRESSURE LESS THAN 90
•RESPIRATORY ARREST/AGONAL RESPIRATIONS
•BLUNT/PENETRATING CHEST TRAUMA
•SUSPECTED PNEUMOTHORAX
•FACIAL TRAUMA/DEFORMITY/BURNS INHIBITING
PROPER MASK FIT
•RECENT FACIAL OR GASTRIC SURGERY
•HIGH RISK OF ASPIRATION/ACTIVE VOMITING
•TRACHEOSTOMY
•PNEUMOTHORAX
How does it work?
• Delivers continuous positive airway
pressure and operator adjustable levels
throughout the breathing cycle
independent of the patient’s flow
requirements which assists overcoming
airway resistance
• Keeps alveoli open and improves
pulmonary gas exchange in patients
with respiratory compromise
Important Aim Of CPAP Is To
Increase Functional Residual
Capacity (FRC)
 Volume of gas remaining in lungs at end-expiration
 CPAP distends alveoli preventing collapse on expiration
 Greater surface area improves gas exchange
CPAP And Acute Respiratory Failure
 CPAP overcomes inspiratory work imposed by
auto-peep
 CPAP prevents airway collapse during exhalation
 CPAP improves arterial blood gas values
 CPAP may avoid intubation and mechanical
ventilation
-Resistance is regulated with a positive
end expiratory pressure (PEEP) valve.
Effects of CPAP
- Increased Functional Residual Capacity
- Reduced Work Of Breathing
- Increased Oxygen Diffusion Across
Alveolar Membrane
- Increased Alveolar Surface Area
Effects of CPAP
Acute Pulmonary Edema
•Changes Pressure Gradients
•Reduces Work of Breathing
•Reduces Sympathetic
Discharge
•Can Decrease Preload
Positive pressure ventilation also decreases blood
return to the heart and may lower blood pressure
SPECIAL CONSIDERATIONS
•CPAP SHOULD BE DISCONTINUED IN THE CASE OF PATIENT
NON-TOLERANCE OR PROGRESSION TO RESPIRATORY
FAILURE
•CPAP SHOULD NOT DELAY THE ADMINISTRATION OF
MEDICATIONS – FOR EXAMPLE: NITRO, ALBUTEROL, ETC.
•ADVISE THE RECEIVING FACILITY OF INITIATION OF CPAP
THERAPY AS SOON AS PRACTICAL
•OBSERVE PATIENT FOR SIGNS/SYMPTOMS OF HYPOTENSION,
RESPIRATORY FAILURE OR GASTIC DISTENSION
•DNR IS NOT A CONTRAINDICATION TO CPAP USE
ADVANTAGES
•PROVIDES POSITIVE PRESSURE VENTILATION WITHOUT THE
NEED FOR INTUBATION
•PERMITS ADEQUATE OXYGENATION WITH LOWER FIO2
•AVOIDANCE OF RISK,COMPLICATIONS AND EXPENSE OF ET
INTUBATION
•DECREASES THE NEED FOR SEDATION/PARALYTICS
•DECREASES THE RISK OF NASOCOMIAL INFECTIONS
ADVANTAGES
•PRESERVATION OF SPEECH
•PATIENT CAN SWALLOW, EAT AND DRINK
•PRESERVATION OF NORMAL AIRWAY DEFENSE MECHANISMS
•IN COPD PATIENTS, MAY REDUCE THE NEED FOR INTUBATION IN
AS MUCH AS 80% OF PATIENTS
•NASAL MASK CPAP HAS BEEN SHOWN EFFECTIVE IN ELDERLY
PATIENTS WITH ACUTE RESPIRATORY FAILURE TO AVOID
INTUBATION
COMPLICATIONS
HEIGHTENED SENSE OF CLAUSTROPHOBIA OR SMOTHERING
ABRASIONS TO THE BRIDGE OF THE NOSE
SIGNIFICANT MASK LEAK MAY LEAD TO RAPID LIFE THREATENING
HYPOXEMIA
PATIENT DISCOMFORT
LOSS OF DEFINITE CONTROL OF AIRWAY AND BREATHING
AEROPHAGIA (HABITUAL AIR SWALLOWING) – LESS COMMON
COMPLICATIONS
•IMPAIRED ACCESS TO AIRWAY FOR SUCTIONING – LESS COMMON
•FACIAL SKIN PRESSURE STRESS – LONG TERM USE
•HIGH EXTERNAL PRESSURE MAY INCREASE INTRATHORACIC
PRESSURES THUS DECREASING VENOUS RETURN AND
DECREASING CARDIAC OUTPUT – RARE COMPLICATION
•POTENTIAL FOR BARATRAUMAS, PNEUMOTHORAX OR
PNEUMOMEDIASTINUM - RARE COMPLICATION
•POTENTIAL FOR ASPIRATION, GASTRIC DISTENTION AND INABILITY
TO CLEAR SECRETIONS – RARE COMPLICATION
LIMITATIONS
•INTERMITTENT USE OF DIURETICS IS REQUIRED IN CHF PATIENTS
•POSITIVE PRESSURE VENTILATION CAN ONLY DECREASE
CONSEQUENCES OF HYPOXEMIA AND DECREASE NEED OF
HIGH CONCENTRATION OF 02. DOES NOT PRECLUDE POOR
OUTCOMES DUE TO OTHER SYSTEMIC DISTURBANCES
•ONLY AN ALTERNATIVE TO STANDARD MECHANICAL VENTILATION
SYSTEM
PRECAUTIONS
•MECHANICAL VENTILATION AND INTUBATION REMAINS THE
MAINSTAY OF TREATMENT FOR PATIENT WITH PERSISTENT
HYPOXIA OR RESPIRATORY MUSCLE FATIGUE
•INTUBATION SHOULD BE AVAILABLE FOR PATIENTS WHO DO NOT
RESPOND TO NON-INVASIVE POSITIVE PRESSURE
VENTILATION
Technician Concerns
with CPAP
1. Monitoring patient respirations
2. Patient vomiting
3. Patient tolerance
4. Ambulance oxygen consumption
PROCEDURE
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DEMONSTRATE BODY SUBSTANCE ISOLATION (BSI) PROCEDURES
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ASSEMBLE AND PREPARE THE EQUIPMENT
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PREPARE CPAP EQUIPMENT AND ADEQUATE OXYGEN SUPPLY
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EXPLAIN CPAP PROCEDURE TO THE PATIENT
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PLACE PATIENT IS A HIGH FOWLER’S POSITION
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PLACE SpO2 MONITORING DEVICE
PROCEDURE
• PLACE ETCO2 DETECTOR ON FACE, IF AVAILABLE, GET INITIAL
READING
• CHECK CPAP FOR OXYGEN FLOW, DIAL UP FOR FLOW, THEN TURN OFF
• HAVE PATIENT HOLD CPAP MASK IN PROPER POSITION WITH PROPER
FORCE
• DIAL UP TO A PEEP STARTING AT 10 CM H20
• COACH THE PATIENT HOW TO BREATHE AND TO RELAX
• USE VERBAL SEDATION, COACH PT THROUGHOUT TRANSPORT (I.E.
“YOU ARE GOING TO FEEL BETTER FROM THE PRESSURE OF THE
MASK”, “BREATHE SLOWLY THROUGH MASK”)
PROCEDURE – CONTINUED
• PLACE THE HEAD STRAPS IF PATIENT WILL ALLOW THEM TO BE USED
• MONITOR THE CPAP CIRCUIT FOR AIR LEAKS
• MONITOR THE FACE MASK PLACEMENT FOR PROPER FIT
• MONITOR THE PATIENT’S RESPIRATORY RESPONSE TO CPAP
• MONITOR THE PATIENT’S TOLERANCE
PROCEDURE – CONTINUED
• MONITOR AND RECORD THE PT’S VITAL SIGNS EVERY 5 MINUTES
• ADMINISTER MEDICATICATIONS AS APPROPRIATE PER PATIENT
CONDITION (FOR EXAMPLE: ADMINISTRATION OF ALBUTEROL
AND NITRO
• MONITOR FOR GASTRIC DISTENTION
• NOTIFY RECEIVING FACILITY AND ADVISE THAT CPAP IS IN USE
SPECIAL NOTES
REMOVE THE CPAP IF THE FOLLOWING SITUATIONS OCCUR:
• PT’S LEVEL OF CONSCIOUSNES DETERIORATES, CAN NOT
FOLLOW COMMANDS
• PT BECOMES UNRESPONSIVE
• PT’S RESPIRATORY STATUS DECLINES, CAN NOT MAINTAIN
AIRWAY
• PT DEGRADES TO AGONAL RESPIRATORY EFFORT OR APNEA
SPECIAL NOTES
REMOVE THE CPAP IF THE FOLLOWING SITUATIONS OCCUR:
• PT DEVELOPS ACTIVE VOMITING OR ACTIVE UPPER GI BLEED
• PT BECOMES CLAUSTROPHOBIC AND CAN NOT TOLERATE
MASK
• PT DEVELOPS ACUTE GASTRIC DISTENSION THAT IS
IMPAIRING RESPIRATORY EFFORT
• PT’S BLOOD PRESSURE DROPS BELOW 90 SYSTOLIC
• HOSPITAL CARDIO-PULMONARY STAFF IS PREPARED TO
IMMEDIATELY TRANSFER THE CPAP CARE
POST CPAP REMOVAL
PREPARE FOR POSSIBLE AIRWAY MANAGEMENT WITH BAG
VALVE MASK (BVM) DEVICE ASSISTANCE
PREPARE FOR POSSIBLE ET INTUBATION, THEN GASTRIC
DECOMPRESSION, IF NEEDED
TRANSITION AT THE EMERGENCY DEPARTMENT
• SUDDEN REMOVAL OF CPAP AT THE ED IS RISKY, SO IT SHOULD BE
CONTINUED UNTIL THE PT IS CLEARLY STABILIZED.
• IT IS IMPORTANT TO GIVE ENOUGH NOTIFICATION TO THE ED SO
THAT THEY CAN NOTIFY RESPIRATORY THERAPY.
• IN MANY INSTANCES, IN-HOSPITAL CPAP AND BiPAP DEVICES ARE
MORE COMPLICATED AND REQUIRE MORE SETUP TIME.
• CPAP WILL DRAIN THE D SIZED CYLINDERS MORE RAPIDLY. BE
PREPARED TO ACCESS THE WALL MOUNTED OXYGEN SOURCES IN
THE ED.
TROUBLESHOOTING
WARNING: TRANSPORT OF PATIENTS WITH CPAP REQUIRE THE
CERTIFIED EMT HAVE A GOOD WORKING KNOWLEDGE OF THE
DEVICE’S USE AND PROBLEM SOLUTION. PROPER EMERGENCY
BACKUP EQUIPMENT OR OTHER MEANS OF POSITIVE-PRESSURE
VENTILATION DEVICE MUST BE IMMEDIATELY AVAILABLE DURING
TRANSPORT.
(1) LOW PRESSURE; UNABLE TO MAINTAIN ABOVE 10 CM H20 AND
INADEQUATE PT RESPIRATORY RESPONSE
PROBABLE CAUSE: LOW SUPPLY OF OXYGEN
SOLUTION: ALWAYS MAKE SURE AN ADEQUATE SUPPLY OF
OXYGEN IS AVAILABLE FOR PT USE AND
TRANSPORT
TROUBLESHOOTING – CONTINUED
(2) MASK SEAL
PROBABLE CAUSE: CHECK FOR PROPER MASK SIZE AND SEAL;
ESPECIALLY AT BRIDGE OF NOSE
LEAK IN BREATHING CIRCUIT
SOLUTION: DISCONNECT THE BREATHING CIRCUIT; ASSIST
OXYGENATION AND VENTILATION AS NECESSARY
(3) HIGH PRESSURE, GASTRIC DISTENTION, INADEQUATE
RESPIRATORY RESPONSE
PROBABLE CAUSE: BLOCKED AIRWAY; SECRETION OR CONTROL
MODULE SETTING ABOVE 10 CM H20
SOLUTION: POSITION AIRWAY; CONSIDER SUCTIONING AND
CHECK THE CONTROL MODULE SETTING AND
ADJUST AS REQUIRED
TROUBLESHOOTING – CONTINUED
(4) FAILURE TO RESPOND TO TREATMENT OF CPAP
SOLUTION: RESPONSE SHOULD BE TO ASSIST OXYGENATION
AND VENTILATION AS NECESSARY VIA OTHER
MEANS
DOCUMENTATION
• CIRCUMSTANCES CONTRIBUTING TO THE DECISION
FOR USING CPAP
• PROCEDURE, PATIENT ASSESSMENT AND OUTCOME
• SUBMIT QUALITY REVIEW FORM (DEPARTMENT)
Continuous Positive Airway Pressure
“Breathing Against A Threshold of Resistance”
“Pneumatic Splinting of Airways”
“Oxygen Therapy In It’s Most Efficient Form”
Assembly Procedures
1. Select appropriate size face piece (S,M,L)
1. Need to create an air tight seal around patient face
2. Explain procedure to patient
1. mask has air tight seal
2. positive pressure (i.e. like breathing placing your head outside a
slowly moving car window
3. Place face mask on patient
1. adjust straps
4. Hook up oxygen tubing to appropriate liter flow on portable or ambulance
oxygen – Maintain 10 cm H2O at 12-15 lpm
Assembly Procedures
5. Place manometer assembly on face piece
Special Featuresof Flow Safe EZ
Can deliver a nebulized patient treatment while maintaining CPAP
1. CPAP has an attached nebulizer
Special Features of Flow Safe EZ
Can deliver a nebulized patient treatment while maintaining CPAP
1. Place nebulizer treatment in canister and reattach to CPAP
2. Adjust green flow meter knob on front of face piece to deliver
nebulizer treatment
Questions ?