3 things you should know about CPAP use in EMS
CPAP technology and practice in the prehospital environment has evolved for application beyond CHF and COPD
After seeing a number of inquiries about the potential uses for CPAP in COVID-19 treatment, we reached out to EMS1 contributors from the Montgomery County Hospital District, Robert Dickson, MD, FAAEM, FACEP, FACEM, MCHD medical director; and Casey Patrick, MD, MCHD assistant medical director, to get their take.
“The bottom line is to avoid all nebs in patients who are not in frank respiratory failure – and, if you have to give them – do it “in line” with NIV, only if you have the proper kit with filter,” Dr. Dickson noted. Read more: Airway management adjustments in the era of COVID-19
Sponsored by Bound Tree Medical
By Tim Nowak for EMS1 BrandFocus
The use of continuous positive airway pressure (better known as CPAP) for respiratory distress patients, like those with pulmonary edema from congestive heart failure, has greatly impacted patient care in a positive way. But there are more uses for CPAP than just CHF patient management.
The “what” of CPAP, along with its “why” have already been established: These tools “splint” open the airway structures when they’re otherwise compromised or collapsed, with the intent to open the airway structures to improve gas exchange surface area in the lungs.
Constriction or compromise can be due to asthma, pulmonary edema from CHF or even emphysema or chronic bronchitis related to chronic obstructed pulmonary disease (COPD).
More potential uses for CPAP have emerged within many healthcare settings, particularly in EMS. Beyond the established “what” and “why” of CPAP are some updates to its “who,” “how,” and “when.” Here are three key things EMS providers should know about using CPAP.
Who Can Use CPAP?
What was once reserved for ALS providers, such as paramedics, has now expanded into the scope of practice for BLS providers, like EMTs. Early adopters of CPAP for BLS providers, like the state of Wisconsin, have extended online and offline (standing order) permission for EMTs to use CPAP for as many as 10 years.
CPAP is a form of noninvasive positive pressure ventilation (NiPPV) support, so patients that meet respiratory distress criteria in some states and communities can benefit from more immediate respiratory care, despite their distance from urban ALS care providers. This valuable time and window of opportunity can aid in drastically reducing the risk of respiratory patients deteriorating and decrease the need for emergent prehospital intubation.
Expanded prehospital use of CPAP has already led to a decreased need for intensive care unit admits due to ventilator dependency for patient care. Much of this is due to the advancements in CPAP equipment, particularly disposable CPAP products.
How is CPAP Delivered?
The expensive pressure generators and “elephant trunks” of CPAP equipment in the past are gone from the prehospital setting. Today’s CPAP devices are a fraction of the overall cost, simple in design and are entirely disposable, from the mask all the way to the oxygen connection.
Rather than being based on a completely closed system, newer prehospital CPAP devices use somewhat of a Venturi effect (for any firefighters in the crowd), where room air and high-flow oxygen are drawn in through a narrow opening in order to increase the positive-end expiratory pressure (PEEP). This allows for a simple setup and oxygen source connection, rather than requiring a separate pressure generator device in order to create sufficient PEEP. With these newer models, simply increasing the oxygen liters per minute increases the flow pressure and subsequent PEEP.
As these devices have become more simplified in their design, they’ve also become more simplified in their application. What once took planting your feet by the patient’s head on the cot for traction, a college degree in aerophysics and a Hershey bar is now accomplished with a technique you can learn in a three-minute training on how to physically secure the mask to the patient’s face.
Considering the “who” and “how” of today’s CPAP use, expanded reasons for its “when” are also available.
When Should Someone Receive CPAP?
Interpreting a capnograph plays a key role in the determination for the use of CPAP versus other treatment modalities. The waveform, not just the end-tidal carbon dioxide (EtCO2) number, is what’s important here.
Does the waveform appear normal or box-shaped? How about “shark-finned” or appearing like it has a downslope?
These simple indicators, combined with physical signs of respiratory distress and abnormal lung sounds, can direct you to where to start. After all, not all that wheezes is asthma!
Here are a few approaches from around the country:
- In the Denver metro area, if awake and alert near-drowning patients develop respiratory distress, CPAP may be indicated.
- For EMS in Wake County (North Carolina), patients that have febrile symptoms with respiratory distress and crackles or rales for lung sounds may be suffering from pneumonia, and may meet the indications for CPAP.
- An asthmatic patient in many parts of the country may need more than just an albuterol and ipratropium bromide nebulizer treatment – they may need a “super-neb!” (a more exciting way of describing an in-line nebulizer with CPAP).
Combined with our already established indications (the “when”) for CPAP use, the advancements in simple and disposable CPAP product designs have greatly increased its overall use by EMS providers. That alone has led to improved patient outcomes.
The fact that CPAP is now a device that can be applied by a single provider has led to less hesitation, less controversy and less annoyance in providing this valuable therapy. If the patient has respiratory distress, think about CPAP. If your nebulizer therapy isn’t working, think about CPAP. Consider how your agency can expand the use of CPAP to improve patient outcomes.
About the Author
Tim Nowak, AAS, BS, NRP, CCEMT-P, SEMSO, is the founder and CEO of Emergency Medical Solutions LLC, an independent EMS training and consulting company that he developed in 2010. He's been involved in EMS and emergency services since 2002, and has worked as an EMT, paramedic and critical care paramedic in a variety of urban, suburban, rural and hospital settings. He’s also been involved as an EMS educator, consultant, item writer, clinical preceptor, board member, reference product developer, firefighter and hazmatat technician throughout his career.