RSS
Continuous Positive Airway Pressure Protocol Refresher and Discussion
The following excerpts are courtesy of Wishard Education and Marion County Protocols:
Remember that CPAP is a second line treatment for respiratory distress from COPD and/or pulmonary edema after the patient has failed pharmacological management as evidenced by: persistent dyspnea/hypoxemia, secondary to to pulmonary edema and/or COPD, and history consistent with heart failure, volume overload, or COPD exacerbation.
Continuous positive airway pressure (CPAP) is a non-invasive method to provide respiratory support to certain patients. CPAP has been shown to rapidly improve vital signs, gas exchange, the work of breathing, decrease the sense of dyspnea, and decrease the need for endotracheal intubation in patients who suffer from shortness of breath from congestive heart failure (CHF) and acute pulmonary edema.
CPAP has been successfully demonstrated as an effective adjunct in the management of pulmonary edema secondary to CHF. CPAP allows time for administered medications to work.
Goals of therapy with CPAP:
Increase the amount of inspired oxygen
Decrease the work of breathing
Decrease the need for intubation
Decrease the length of hospital stay
Decrease the mortality rate
Marion County Protocol:
Indications: Age greater than or equal to 18 years old, has the ability to maintain and protect an open airway, Systolic BP at or above 90 mm HG, pulse oximetry <92% on 100% oxygen, plus at least two of the following; severe onset of dyspnea, respiratory rate > 25/minute, accessory muscle use, dyspnea at rest, rales or wheezes.
Contraindications: respiratory or cardiac arrest, agonal respirations, suspected or confirmed pneumothorax or penetrating chest trauma, inability to maintain a patent airway, any impediment to proper mask placement or seal (facial trauma, stroke, facial anomalies, epistaxis), tracheostomy, persistent nausea and vomiting/upper GI bleeding, inability to comply with the device due to severe anxiety or altered mental status.
Procedure: Assure patent airway, place patient on EKG monitor and pulse oximetry; capnography if available, explain procedure to patient. CPAP DOES NOT REPLACE PHARMACOLOGY- initiate medications first if applicable: if suspected pulmonary edema and SBP > 90 mm Hg administer three 0.4 mg doses of NTG SL and repeat three 0.4 mg doses every 3 minutes if SBP remains at or above 90 mm Hg and the patient remains dyspneic (*Remember to avoid the use of NTG in the setting of Viagra, Levitra, Cialis, or other ED drug use.)
If reactive airway disease is suspected, give albuterol 5 mg though the circuit every 10 minutes if patient remains dyspneic.
If the second round of pharmacological therapy fails to resolve the patient’s dyspnea, and they remain hypoxemic (oxygen saturation <92% on 100% oxygen) then CPAP may be initiated.
Use of CPAP device:
*Ensure adequate oxygen supply to device, if needed, set manufacturers recommended airflow
*Place mask and hold in place as patient adjusts to ventilatory support
*Encourage patient to breath deeply
*Secure mask, check for air leaks and if recommended by manufacturer, increase liter flow as needed
*Contact receiving facility as early as possible to allow RT to prepare their equipment
*Monitor and document patient's vitals and pulse oximetry
*Do not use chemical restraint protocols for patients on CPAP
*If patient deteriorates, remove device and consider BVM ventilations or endotracheal intubation
How has CPAP changed your management and outcome of CHF and/or acute pulmonary edema patients on the street? What problems have you encountered? What advice would you offer those who have not used CPAP? Do you have any positive or negative feedback about this protocol change?
I work up in North West IN and we have as a standing order to use CPAP on all CHF pt’s who are maintaining there own airway when we have an ETA greater than 5 mins to to the ED. The few times that we have had to use it the pt’s improved by 100% from when we initiated care to the point where they have been able to talk to us and there o2 sats increase. I am a huge fan of CPAP in the field. I think all EMS providers should look into carrying them. Granted we still do treat them therapeutically with Ng and Lasix. I feel Lasix should still be an on ALS units, I heard that it has been taken out of Marion County Protocols? Why?
Lasix was removed from the MC protocols for 2 reasons. First, because our transport times are very short (less than 12 minutes for nearly 90% runs) and there is little therapeutic benefit to administering lasix in our environment. It was not changing outcomes. Secondly, the vast majority of our chf patients suffer from high afterload (high SBP) issues. NTG is the definitive rescue drug for these patients. Case review revealed that we were failing to administer adequate doses of nitro, and continuing to push lasix (a second line drug) aggressively. Does lasix help? Of course. But we must first optimize ventricular preload and reduce pulmonary and peripheral vascular resistance before relying on lasix to have any value. For years we have heard lasix lasix lasix for CHF when the real answer is nitro nitro nitro. Nitro does change outcomes, and should be the focus for our prehospital providers in MC
Having had a chance to try out the new ‘three nitro a time’ protocol, I have to agree with Dr Miramonti. I have seen near instantaneous improvement both times I had the opportunity to use it. Neither one needed CPAP after the higher dosage of nitro. Giving Lasix, I can’t say with any confidence that I have truly ever improved anyone’s condition.
And I’m an old school guy, too. Changes don’t come easy to us. This is one I have embraced.