Transcript CPAP for Medical Directors

Pre-Hospital CPAP
What the EMS Medical
Director should know
Keith Wesley, MD
Wisconsin State EMS Medical Director
[email protected]
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 prehospital providers
Discuss the methods for implementing
pre-hospital CPAP
The Goal of CPAP?
Reduce the need for prehospital 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
The Problem
Congestive Heart Failure
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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 nonintubated patients
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 preload and after-load as well as remove
interstitial fluid
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
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
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 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 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
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
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
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 Experience
Data Summary Sept. 1996 – May 1997
 Total intubations 22
 Hospital stay 14.8 days
 ICU admission 100%
Data Summary Sept. 1997 – May 1998
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CPAP 50
Total intubations 8 (15%)
CPAP failures 4 (8%)
Hospital stay 8 days
ICU admission 48%
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 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
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)?
No
Contact Medical Control
Consider ALS Intercept and Transport
Yes
If Basic IV Tech:
Administer 1 spray
sublingual NTG every
5 minutes as long as
systolic BP is greater than
100mmHg
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 CPAP
Congestive Heart Failure
COPD / Asthma
Pneumonia
Patient condition is stable
or improving
Continue CPAP
Reassess patient every
5 minutes
Asses Patient, record vital signs
and pulse ox before applying oxygen
Does the Patient meet two or more
Inclusion Criteria?
No
Yes
Does the Patient meet any
Exclusion Criteria?
Yes
Continue standard BLS
Respiratory Distress Protocol
No
Administer CPAP
5 cm H2O of pressure AND
Notify Medical Control
Consider ALS Intercept
and continue BLS
Respiratory Distress Protocol
Reassess patient, vital signs, and
respiratory distress scale every 5 min.
Patient condition is deteriorating
Decreasing LOC
Decreasing Pulse Ox
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 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 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
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 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
CHF
Pulmonary Edema
– Near Drowning
– Inhalation Exposure
COPD
Asthma
Pneumonia
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 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 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
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?