Transcript CPAP for Medical Directors - Emergency Medical Resources

Joe Holley, MD FACEP
EMS Medical Director, State of Tennessee
Member, ACEP EMS Committee
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
NIPPV is an important prehospital treatment modality for acute dyspnea.
EMS agencies should select NIPPV systems and develop
dyspnea care protocols suited to their patient
populations, clinical capabilities, and receiving
emergency department뭩 resources.
EMS agencies must conduct quality assurance and
inspection efforts to verify the safety and effectiveness
of NIPPV.
 PREHOSPITAL EMERGENCY CARE 2011;15:418
Reduce the need for pre-hospital intubation!
CPAP vs. Intubation
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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
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personnel
Significant complications
Can require sedation or RSI
Potential for infection
Intensive Resource
Utilization
Impact on the System
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 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 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 prehospital arena – usually requires RSI
Physiology of CPAP
 Airway pressure maintained at set level throughout
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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
EFFECTIVENESS OF
PREHOSPITAL CONTINUOUS POSITIVE AIRWAY PRESSURE
IN THE
MANAGEMENT OF ACUTE PULMONARY EDEMA
Michael W. Hubble, PhD, NREMT-P, Michael E. Richards, MD, MPA, Roger Jarvis,
EMT-P, Tori Millikan, EMT-P, Dwayne Young, BS, EMT-P
PREHOSPITAL EMERGENCY CARE 2006;10:430–439
 95 patients received standard therapy, and 120 patients
received CPAP and standard therapy for Pulmonary Edema
 Intubation was required in 8.9% of CPAP-treated patients
compared with 25.3% in the control group (p = 0.003), and
mortality was lower in the CPAP group than in the control
group
 When compared with the control group, the CPAP group
had more improvement
 Patients receiving standard treatment were more likely to
be intubated and more likely to die than those receiving
standard therapy and CPAP.
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”
Pre-hospital CPAP
 PEC 2000 NAEMSP Abstract, “Pre-hospital use of CPAP for
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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”
Types of Positive Pressure
Ventilation
1) continuous positive airway pressure (CPAP)
applies uniform supportive pressure during both
inspiratory and expiratory phases.
2) bilevel positive airway pressure (BiPAP) is similar to
CPAP but alternates different levels of inspiratory and
expiratory pressure.
 Both CPAP and BiPAP systems typically provide
pressure support of 4-10 cmH2O.
Is it Cost Effective?
 Hubble et al. evaluated the cost-effectiveness of
prehospital CPAP in acute pulmonary edema.
 Using data from their 2006 publication, they predicted
that four of every 1,000 EMS patients would require
CPAP for acute pulmonary edema, resulting in 0.75
lives saved.
Is it Cost Effective?
 Accounting for the cost of CPAP equipment, including the
cost of the CPAP-generating system, disposable mask, and
tubing for each patient, training of personnel, and oxygen
usage, the authors estimated that the cost-benefit of
prehospital CPAP was $490 per life saved.
 They also predicted that CPAP would reduce
hospitalization costs by $4,075 per year per application.
 Didn’t include the value of avoiding the ICU, Mechanical
Ventilation, Complications, or availability of ICU bed for
“the Next Patient”….potentially worth thousands of dollars
Delivery System Types
 External Pressure Regulated
 Turbulent Flow Virtual Valve
External Pressure Regulated
 Regulator-based portable NIPPV systems generate
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continuous pressure from oxygen flow, directly
controlling inspiratory and expiratory pressure.
Regulator-based NIPPV systems allow different
inhaled oxygen fractions, reducing oxygen
consumption.
At 10 cmH2O pressure and 100% inspired oxygen
(flowrate of 15 L/min), a size D oxygen cylinder will last
between 20 and 30 minutes.
At 65% inspired oxygen, a size D oxygen cylinder may
last approximately 35 minutes.
Regulator-based systems are often compatible with
end-tidal capnometry and in-line medication
nebulizers.
Disadvantages
 A disadvantage of regulator-based systems is their size;
portable NIPPV regulators weigh approximately 3
pounds.
 Regulator-based systems are also expensive; the
regulator costs $1,000-1,500, and each disposable hose
circuit costs $25-50.
 Portable NIPPV systems may not be compatible with
hospital wall oxygen outlets.
 During transition of care to the ED, EMS personnel
may need to rely on portable oxygen tanks to maintain
NIPPV operation until the availability of hospital
NIPPV equipment.
Turbulent Flow Virtual valve.
 The Boussignac CPAP system uses a different NIPPV
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approach, accelerating oxygen flow through a series of
channels to create turbulence.
The turbulence acts as a virtual valve, generating
positive airway pressure.
The system is lightweight and disposable (single use)
and uses a conventional oxygen source and flow
regulator.
Each disposable circuit costs approximately $70.
On arrival at the ED, EMS personnel may transfer the
system to hospital wall oxygen, thus minimizing care
transfer delays.
Disadvantages
 A disadvantage of the Boussignac system is its limited
maximum positive pressure of ~10 cmH2O with an
oxygen flow of 25 L/min.
 Consequently, the system requires large quantities of
oxygen.
 For a CPAP pressure of 5.0 cmH2O, a size D oxygen
cylinder will last approximately 23 minutes.
 To generate a CPAP pressure of 10 cmH2O, a size D
cylinder will last 14 minutes.
Transport Ventilators
 Select transport ventilators may be designed to provide
BiPAP or CPAP.
 While dependent on the individual brand and model,
the process involves placing the ventilator in pressure
support mode, setting a desired inspiratory pressure
support value, and setting a desired positive endexpiratory pressure (PEEP) value.
Indications for CPAP
 The general indication for NIPPV is dyspnea accompanied
by early respiratory failure in patients with intact protective
airway reflexes and mental status.
 CHF
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Pulmonary Edema
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Near Drowning
Inhalation Exposure
COPD
Asthma
Pneumonia
Possible Indications
 While utilized in in-hospital practice, the role of
NIPPV for pneumonia-associated respiratory failure is
less clear.
ContraIndications
 Patients with severe respiratory distress may not
tolerate NIPPV.
 not suitable for patients with an absence of a gag reflex
or altered mental status.
 not be able to cooperate with NIPPV
 increased risks of vomiting and aspiration
 consider ETI for these patients.
Use In Trauma?
 The utility in major trauma is unclear
 Invasive airway management of major trauma is
difficult, and NIPPV may provide transient ventilatory
support in these patients.
 However, potential NIPPV pitfalls in the setting of
trauma include the risk of pneumocephalus,
subcutaneous emphysema or bacterial meningitis in
patients with midface fractures, pneumothorax in
thoracic trauma, and increased intrathoracic pressure
causing hypotension
Generally Accepted
ContraIndications
 Patient less than eight years of age (Fitment Issues)
 Unable to maintain a patent airway
 Decreased level of consciousness (LOC)
 Pneumothorax
 Facial trauma/burns
 Systolic BP < 90 mmHg
 Recent surgery to face or mouth
 Epistaxis
 Patient unable to tolerate mask or pressure
 Pneumonia (relative contraindication)
What about the Hypoxic Drive
Issue?
 Certainly this physiologic phenomenon exists, it is relatively
uncommon and many hypoxic COPD patients have been denied much
needed oxygen out of fear of causing worse hypercapnia. As a result,
left ventricular function suffers as does renal, mental and other related
issues.
 Moreover, when this phenomenon does occur, it is in the setting of
non-pressurized oxygen delivery (read nasal cannula or face masks)
and not with CPAP, BiPAP or intubation and placement of the patient
on mechanical artificial ventilation. All three of these modalities
resolve hypercapnia by increasing alveolar ventilation. Recall that as
alveolar ventilation goes up, PaCO2 goes down and respiratory acidosis
lessens.
 The COPD patient with known hypercapnia should never be
transported to the ED on non-pressurized oxygen. However, hypoxic
COPD patients can be safely transported with supplemental oxygen
driven by CPAP.
Intubation
 Patients who cannot cooperate, maintain their own airway,
or have adequate respiratory effort are not candidates for
CPAP. They require immediate intubation.
 Monitor your patient for a failure to respond to CPAP, as
noted by a declining mental status or ability to comply with
CPAP. Not all patients will respond, and may require
intubation.
 Patients who have intractable vomiting may not be able to
protect their airway, and need intubation.
Training
Key elements of training should cover:
 Pathophysiology of acute dyspnea
 Physiology of NIPPV systems
 Description of CPAP and BiPAP mechanics, with focus on the systems available to the
individual EMS agency
 Indications and contraindications for NIPPV
 Initiation and titration of NIPPV therapy
 Titration of concurrent pharmacologic therapy
 Management of adverse events
 Transition of care at the receiving hospital
 Alternate care strategies
Training
 The technique of NIPPV application will vary with the
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employed system.
Application of the face mask must ensure a tight seal.
Facial hair may require trimming to achieve a tight
seal.
An adequate mask seal may not be possible with
edentulous patients or individuals with facial
abnormalities.
Patient Coaching is very important to successful
application
Application in the Field
 Continuous positive airway pressure systems have single
pressure setting for both inspiration and expiration. A
typical initial setting is 5 cmH2O, with pressure
adjustments every few minutes in response to the patient’s
subjective and objective work of breathing, respiratory rate,
and oxygen saturation.
 The typical range of pressure settings is 5-10 cmH2O.
 Bilevel positive airway pressure is similar to CPAP, but
alternates a higher inspiratory pressure with a lower
expiratory pressure.
 Typical initial settings include an inspiratory pressure of 10
cmH2O and an expiratory pressure of 5 cmH2O, with
subsequent adjustments according to patient response.
Medication Administration
 Many CPAP devices allow for the concurrent
administration of nebulized medications.
 Medications are generally more effective due to
improved recruitment, airway patency, and pressure
support.
 Indications for Bronchodilators are the same
regardless of the use of CPAP
Patient Monitoring
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Respiratory rate: A reduction in respiratory rate (and effort) may indicate clinical response to
NIPPV.
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Heart rate: Improvement in ventilation and perfusion with NIPPV may reduce the heart rate.
However, the heart rate may also increase in response to increased intrathoracic pressure and
decreased venous return.
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Systolic blood pressure: The increase in intrathoracic pressure from NIPPV may decrease venous
return to the heart, leading to a decrease in blood pressure. The development of hypotension (systolic
blood pressure <100 mmHg) or hypoperfusion (cyanosis, decreased capillary refill) may indicate the
need for reduced NIPPV support.
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Oxygen saturation: Oxygen saturation may improve with application of NIPPV.
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End-tidal capnography: End-tidal carbon dioxide (ETCO2) monitoring to gauge NIPPV response.
Upon initial application of NIPPV, ETCO2 may increase from improvement in ventilatio/perfusion
mismatch. Decreasing ETCO2 may reflect respiratory improvement from NIPPV.
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Subjective dyspnea ratings of patient subjective dyspnea, auscultation intensity, cyanosis, and
accessory respiratory muscle use.
Wisconsin EMT–Basic Experience
 Question: Can EMT-Basics apply CPAP as safely as
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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
Yes
If Basic IV Tech:
Administer 1 spray
sublingual NTG every
5 minutes as long as
systolic BP is greater than
100mmHg
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
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
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
Conditions Indicated for CPAP
Congestive Heart Failure
COPD / Asthma
Pneumonia
Patient condition is stable
or improving
Continue CPAP
Reassess patient every
5 minutes
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
Notify Medical Control
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
Implementation in Your System
 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
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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
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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
The Future
 NAEMSP is a strong supporter of CPAP in the field
 The Data is very solid supporting its use
 Safety
 Cost effectiveness
 Its SIMPLY the RIGHT THING for OUR Patients!!
What’s the holdup?
 Yet to be recognized by payors as a separate billable
service.
 Medicare currently will only pay if its used in
conjunction with Endotracheal Intubation!!
 What’s the Point!!!!
Hospitals have been slow to adopt
Efficiencies Improve if adopted on a system wide basis
Joe Holley, MD FACEP