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Pre-Hospital CPAP What the EMS Medical Director should know. Keith Wesley, MD Wisconsin State EMS Medical Director drwesley@charter.net. Objectives. Review the goal & physiology of CPAP Discuss the indications and contraindications for CPAP use Review the literature supporting CPAP use

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pre hospital cpap what the ems medical director should know

Pre-Hospital CPAPWhat the EMS Medical Director should know

Keith Wesley, MD

Wisconsin State EMS Medical Director

drwesley@charter.net

objectives
Objectives
  • Review the goal & physiology of CPAP
  • Discuss the indications and contraindications for CPAP use
  • Review the literature supporting CPAP use
  • Explore the role of CPAP use by pre-hospital providers
  • Discuss the methods for implementing pre-hospital CPAP
the goal of cpap

The Goal of CPAP?

Reduce the need for pre-hospital intubation!

cpap vs intubation
CPAP

Non-invasive

Easily discontinued

Easily adjusted

Use by EMT-B

Minimal complications

Does not require sedation

Comfortable

Intubation

Invasive

Intubated stays intubated

Requires highly trained personnel

Significant complications

Can require sedation or RSI

Potential for infection

CPAP vs. Intubation
the problem
The Problem
  • Congestive Heart Failure
    • Incidence 10 per 1000 patient (over age 65) transports
    • 25% of Medicare Admissions
    • Average LOS is 6.7 days
    • 6.5 million hospital days
    • Those who get intubated have significantly longer LOS
    • 33% get intubated without non-invasive pressure support
    • Intubated patients have 4 times the mortality of non-intubated patients
the problem6
The Problem
  • CHF/Pulmonary Edema
    • Interstitial fluid interferes with gas exchange (ventilation and oxygenation)
    • Increased myocardial workload resulting in higher oxygen demands (many of these patients are suffering ischemic heart disease)
    • Traditional therapies designed to reduce pre-load and after-load as well as remove interstitial fluid
the problem7
The Problem
  • COPD/Asthma
    • Increased work of breathing
    • Hypercarbic (ventilation issue)
    • Traditional therapies involve brochodilators which require adequate ventilation
    • Higher mortality rate if intubated
    • Difficult to wean once intubated
    • Extremely difficult patient to intubate in the pre-hospital arena – usually requires RSI
physiology of cpap
Physiology 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 literature
Supporting Literature
  • JAMA December 28, 2005 “Noninvasive Ventilation in Acute Cardiogenic Edema”, Massip et. al.
    • Meta-analysis of studies with good to excellent data
    • 45% reduction in mortality
    • 60% reduction in need to intubate
supporting literature10
Supporting Literature
  • Reviews in Cardiovascular Medicine, vol. 3 supl. 4 2002, “Role of Noninvasive Ventilation in the Management of Acutely Decompensated Heart Failure”

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

supporting literature11
Supporting Literature
  • Brochard (French abstract) “ Noninvasive ventilation for acute exacerbations of COPD”

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

bipap vs cpap
BiPAP vs CPAP
  • European Respiratory Journal, vol. 15 2000 “Effects of biphasic positive airway pressure in patients with chronic obstructive lung disease”
    • BiPAP resulted in overall higher intrathoracic pressures – reduces myocardial perfusion
    • BiPAP resulted in lower tidal volumes
    • BiPAP resulted in higher WOB
pre hospital cpap
Pre-hospital CPAP
  • PEC 2000 NAEMSP Abstract, “Pre-hospital use of CPAP for presumed pulmonary edema: a preliminary case series”, Kosowsky, et. al.
  • 19 patients
  • Mean duration of therapy 15.5 minutes
  • Oxygen sat. rose from 83.3% to 95.4%
  • None were intubated in the field
  • 2 intubated in the ED
  • 5 subsequently intubated in hospital
  • “Pre-hospital CPAP is feasible and may avert the need for intubation”
utmb experience
UTMB Experience
  • Dr. Jeffery Miller – UT Galveston
  • IRB approval through UTMB
  • 6 hours didactic instruction
  • Recognize CHF – trial limited to CHF
    • Differentiate CHF, COPD, Asthma & Bronchitis
    • 2 hours clinical training
  • Instruction on assessment most important reason for success
utmb experience15
UTMB Experience
  • Data Summary Sept. 1996 – May 1997
    • Total intubations 22
    • Hospital stay 14.8 days
    • ICU admission 100%
  • Data Summary Sept. 1997 – May 1998
    • CPAP 50
    • Total intubations 8 (15%)
    • CPAP failures 4 (8%)
    • Hospital stay 8 days
    • ICU admission 48%
wisconsin emt basic experience
Wisconsin EMT–Basic Experience
  • Question: Can EMT-Basics apply CPAP as safely as Paramedics?
  • 50 EMT-Basic services
  • 2 hour didactic, 2 hour lab, written and practical test
  • Required data collection
  • Compared to same data collected by ALS services during same period
wisconsin emt basic experience17
Wisconsin EMT–Basic Experience
  • Required data collection
    • Criteria used to apply CPAP
    • Absence of contraindications
    • Q 5 min. vital signs including oxygen sats.
    • Subjective dyspnea score
  • Because EMT–Basics don’t diagnose a unique “Respiratory Distress” protocol used to capture patients
slide18

Adult Respiratory Distress Protocol

(Age greater than 12)

Routine Medical Assessment

Oxygen

2 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

Yes

See Mask CPAP Protocol

No

Is the Patient wheezing and/or does

the Patient have a history of Asthma/COPD?

Yes

Administer Albuterol /

Atrovent by Nebulizer

No

Does the Patient have rales and/or does the

Patient have a history of congestive heart

failure (CHF)?

If Basic IV Tech:

Administer 1 spray

sublingual NTG every

5 minutes as long as

systolic BP is greater than

100mmHg

Yes

No

Contact Medical Control

Consider ALS Intercept and Transport

slide19

Mask CPAP for EMT-Basic

Asses Patient, record vital signs

and pulse ox before applying oxygen

  • 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 CPAP
  • Congestive Heart Failure
  • COPD / Asthma
  • Pneumonia

Does the Patient meet two or more

Inclusion Criteria?

No

Yes

Yes

Does the Patient meet any

Exclusion Criteria?

Continue standard BLS

Respiratory Distress Protocol

No

Administer CPAP

5 cm H2O of pressure AND

Reassess patient, vital signs, and

respiratory distress scale every 5 min.

Patient condition is deteriorating

Decreasing LOC

Decreasing Pulse Ox

Notify Medical Control

Consider ALS Intercept

and continue BLS

Respiratory Distress Protocol

Patient condition is stable

or improving

Continue CPAP

Reassess patient every

5 minutes

Notify Medical Control

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

Remove CPAP

Apply BVM Ventilation

wisconsin emt basic experience20
Wisconsin EMT-Basic Experience
  • Results (preliminary – study completed 11/05)
    • 500 applications of CPAP (114 services)
    • 99% met criteria for CPAP on review of medical director
    • No field intubations by those services with ALS intercepts
    • No significant complications
    • All oxygen sats. improved, dyspnea reduced by average of 50%
wisconsin emt basic experience21
Wisconsin EMT – Basic Experience
  • State approved CPAP for EMT-Basic scope of practice 2/06
  • Questions yet to be answered
    • What conditions did the patients have?
    • Was it applied too liberally?
  • Key Point
    • Services without ALS intercept did just as well as those with it
eau claire fire experience
Eau Claire Fire Experience
  • Paramedic service
  • July 2003 – June 2004
  • Measured end-tidal CO2, oxygen sats., and subjective dyspnea score
  • COPD/Asthma – Continuous nebs
  • CHF – Nitro infusion or repeated sprays
eau claire fire experience23
Eau Claire Fire Experience
  • 50 applications
  • No field intubations
  • Initial CO2 levels average 62
  • All patients CO2 levels increased during first 5 minutes
  • CO2 levels increasing more than 10 positively predicted CPAP failure
indications for cpap
Indications for CPAP
  • CHF
  • Pulmonary Edema
    • Near Drowning
    • Inhalation Exposure
  • COPD
  • Asthma
  • Pneumonia
items to consider
Items to Consider
  • How good is current care for respiratory distress?
    • Aggressive nitrates for CHF?
    • Aggressive use of bronchodilators?
    • Pre-hospital and hospital intubation rate?
  • Requires active medical oversight
    • Airway management is a sentinel event
  • ALS or BLS or BOTH?
items to consider26
Items to Consider
  • Equipment
    • Must be easy to use and portable
    • Adjustable to patient’s need
    • Easily started and discontinued
    • Provide quantifiable and reliable airway pressures
    • Conservative oxygen utilization
    • Not interfere with administration traditional therapies for underlying condition
items to consider27
Items to Consider
  • Oxygen concentration
    • Fixed versus Variable rates
      • Fixed rates are either 35% or 100% in current models but actual concentration will be less depending on leaks and minute ventilation
      • Variable rate increases chance of inadequate oxygen supply
    • Pressure level
      • Most studies show 5cm H20 sufficient
      • Complication rate goes up with pressure
summary
Summary
  • 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