CPAP
For
ALS & BLS
CAP Module 2 - CPAP (GHEMS/DG_V2015)
CPAP Curriculum
Introduction
Review of Anatomy and Physiology
CPAP Overview
Pulse Oximetry
Review of Respiratory Distress
Treatment With CPAP
CAP Module 2 - CPAP (GHEMS/DG_V2015)
What is CPAP?
Continuous Positive Airway Pressure
(CPAP)
A non-invasive alternative to intubation
Does not require any sedation
It provides comfort to the patient with
acute respiratory distress by reducing
work of breathing
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Why CPAP?
Respiratory Distress is a common reason
why people call 911!
Established therapeutic alternative
Easily applied, easily discontinued
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Key Points of CPAP
CPAP has been successfully
demonstrated as an effective adjunct in
the management of a variety of respiratory
distress states.
CPAP may prove to be a viable alternative
in many patients previously requiring
endotracheal intubation by prehospital
personnel.
CAP Module 2 - CPAP (GHEMS/DG_V2015)
CPAP vs. Intubation
CPAP
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Non-invasive
Easily discontinued
Easily adjusted
Use by EMT-B
Does not require
sedation
– Comfortable
Intubation
– Invasive
– Usually don’t extubate
in field
– Potential for infection
– Requires highly
trained personnel
– Can require sedation
– Traumatic
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Review of Anatomy &
Physiology
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Elements of the Airway
UPPER AIRWAY
Nares
Nasopharynx
Oropharynx
Tongue
Epiglottis/Glottis
Vocal Cords
LOWER AIRWAY
Trachea/Esophagus
Carina
Main stem Bronchi
Secondary Bronchi
Bronchioles
Alveoli
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Upper Airway
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Pharynx
Nasopharynx
– Uppermost portion of airway,
just behind nasal cavities
– Nasal septum
– Vestibule
– Olfactory membranes
– Sinuses
Oropharynx
– Begins at the level of the
uvula and extends down to
the epiglottis
– Opens into the oral cavity
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Larynx
Three main functions:
– Air passageway between the pharynx and
lungs
– Prevents solids and liquids from entering the
respiratory tree
– Involved in speech production
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Larynx
An outer casing of nine cartilages
– Thyroid cartilage
– Cricoid cartilage
Only complete cartilaginous ring in the larynx
– Epiglottis
Hyoid bone
Cricothyroid membrane
Vocal cords
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Lower Airway
CAP Module 2 - CPAP (GHEMS/DG_V2015)
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Lungs
Principal function is respiration
Attached to heart by pulmonary arteries
and veins
Separated by mediastinum and its
contents
Base of each lung rests on the diaphragm
Apex extends 2.5 cm above each clavicle
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Pleural Cavity
A separate pleural cavity surrounds each
lung
Two layers (visceral and parietal)
Pleural space
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Respiratory System Physiology
The respiratory
system functions as a
gas exchange system
Oxygen is diffused
into the bloodstream
for use in cellular
metabolism
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Respiratory System Physiology
Wastes, including
carbon dioxide, are
excreted from the
body via the
respiratory system
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Ventilation
Ventilation refers to the process of air
movement in and out of the lungs
The volume of air moved in each breath is
the tidal volume
The volume still remaining in the chest
after exhalation is the functional reserve
capacity. FRC
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Inspiration and Expiration
Inspiration
– Chest wall expands
– Lung space increases
– Pressure gradient causes gas to flow into the
lungs
Expiration
– Chest wall relaxes
– Elastic recoil causes thorax and lung space to
decrease in size
– Pressure gradient created in thoracic cavity
causes air to move out of the chest
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Pressure Changes During Inspiration and
Expiration
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Mechanics of Breathing
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Mechanics of Respiration
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Ventilation
The following must be intact for ventilation
to occur:
– Neurologic control to initiate ventilation
– Nerves between the brainstem and the
muscles of respiration
– Functional diaphragm and intercostal muscles
– A patent upper airway
– A functional lower airway
– Alveoli that are functional and not collapsed
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Diffusion
In order for diffusion to
occur, the following
must be intact:
– Alveolar and capillary
walls that are not
thickened
– Interstitial space
between the alveoli
and capillary wall that
is not enlarged or filled
with fluid
CAP Module 2 - CPAP (GHEMS/DG_V2015)
How does CPAP work
Splints the upper airway preventing
collapse
Uses continuous oxygen flow with
pressure to push air into the lungs and
push the fluid into the bloodsteam
Recruits alveoli that have collapsed
CAP Module 2 - CPAP (GHEMS/DG_V2015)
CPAP Mechanism
Increases pressure within
airway.
Airways at risk for
collapse from excess fluid
are stented open.
Gas exchange is
maintained
Increased work of
breathing is minimized
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Pulse Oximetry
Basic concept of Pulse Oximetry
monitoring.
– Objectively determines oxygenation status
when applied correctly.
– Measures the hemoglobin saturation in the
bloodstream
via red and infrared light, through the skin to the
arterial bed.
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Pulse Oximetry
Possible invalid readings
– Low blood flow states, (i.e., shock states,
hypothermic, hypovolemia) may show an inaccurate
low oxygenation percent.
– Carbon monoxide poisoning may show a false high
percent reading.
– Anemias and oxygen capacity carrying diseases (i.e.,
sickle cell) may also show a false high reading.
– Fingernail polish, excessive grease and dirt, nail-tips,
or gel nails may cause a false low reading.
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Review of Respiratory
Distress
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Respiratory Distress
Work of Breathing
– Respiratory rate greater than 25/minute
– The presence of retractions and/or use of
accessory muscles
Appearance = Mental Status
– Pulse Oximetry < 94%
– Effects of hypoxia and hypercarbia
indistinguishable
Circulation/Skin Color
– Severe cyanosis
– Pallor and diaphoresis
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Primary Assessment
Ascertain the patient’s chief complaint that may
include:
– Dyspnea
– Chest pain
– Cough
Productive
Non-productive
Hemoptysis
– Wheezing
– Signs of infection
Fever, chills
Increased sputum production
CAP Module 2 - CPAP (GHEMS/DG_V2015)
History
Previous experiences with similar/identical
symptoms
Known pulmonary diagnosis
Medication history
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Current medications
Medication allergies
Pulmonary medications
Cardiac-related drugs
History of the present episode
Exposure and smoking history
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Secondary Assessment
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Lung Sounds
Work of Breathing - including Rate
Chest Wall Movement
Pulse Oximetry
Skin Color
Vital Signs
Level of Consciousness
Associated Symptoms
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Pulmonary Edema – Congestive
Heart Failure
Defined
– Fluid which collects in the lung tissue and
alveoli
Signs/Symptoms/Assessment
– Anxious, Pale, Clammy, Dyspnea,
Tachypnea, Confusion, Edema, Hypertension,
Diaphoretic
– Rales, Ronchi, Tachycardia, JVD, Pink Frothy
Sputum, Cyanosis
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Pulmonary Edema – Congestive
Heart Failure
Signs/Symptoms/Assessment
– Fatigue
– Nocturia
– Dyspnea on exertion
– Paroxysmal nocturnal dyspnea
– Chest Pain
– Orthopnea
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Pulmonary Edema – Congestive
Heart Failure
Treatment
– Focused history and physical exam
– Complains of trouble breathing.
Airway control w/ adequate ventilation
Oxygenation
– Has a prescribed nitroglycerine available.
Consult medical direction.
Facilitate administration of nitroglycerine
– Baseline vital signs.
– Reassess
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Chronic Obstructive Pulmonary
Disease (COPD)
Defined
– Lung tissue loses elasticity secondary to
destruction of the alveoli (Emphysema)
– Inflammation of the bronchial tree. Diagnosed
by productive cough which lasts at least three
months a year for at least two consecutive
years (Chronic Bronchitis)
– Any COPD patient may have both
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Chronic Obstructive Pulmonary
Disease (COPD)
Signs/Symptoms/Assessment
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Exertional dyspnea
Productive cough/wheezing
Minor hemoptysis
Tachypnea/exertional muscle use
Pursed lip exhalation
May have coarse crackles
Accessory muscle use
Hyperexpansion of the thorax (diminished breath
sounds)
– Excessive caloric expenditure
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Chronic Obstructive Pulmonary
Disease (COPD)
Signs/Symptoms/Assessment
– Tachypnea, cyanosis, agitation, tachycardia,
hypertension
– Confusion, tremor, stupor, apnea
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Chronic Obstructive Pulmonary
Disease (COPD)
Treatment
– Focused history and physical exam
– Complains of trouble breathing.
Airway control w/ adequate ventilation
Oxygenation
– Has a prescribed inhaler available.
Consult medical direction.
Facilitate administration of inhaler
Repeat as indicated.
– Baseline vital signs.
– Reassess
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Asthma
Defined
– Condition which causes the bronchi to
constrict making it difficult to exhale (air
trapping)
– May be caused by allergic reactions and/or
emotional distress
– The most serious form, status asthmaticus, is
a true life-threatening emergency
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Asthma
Signs/Symptoms/Assessment
– Dyspnea, chest tightness, wheezing, and
cough
– Obvious SOB, wheezing, accessory muscle
use, paradoxical respirations,
hyperresonance, prolonged expiration
– Change in Mental Status: agitation, confusion,
lethargy, exhaustion
– Cardiac Arrhythmias
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Asthma
Treatment
– Focused history and physical exam
– Complains of trouble breathing.
Airway control w/ adequate ventilation
Oxygenation
– Has a prescribed inhaler available.
Consult medical direction.
Facilitate administration of inhaler
Repeat as indicated.
– Baseline vital signs.
– Reassess
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Pneumonia
Defined
– Inflammation of both the bronchioles and
alveoli
– May be viral, bacterial, or fungal. Spread by
droplets or contact with infected person
– Common cause of death in North America
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Pneumonia
Signs/Symptoms/Assessment
– Acute onset of chills, fever, dyspnea, pleuritic
chest pain, cough, adventitious breath
sounds.
– In geriatric patients, the primary sign may be
an altered mental state.
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Pneumonia
Treatment
– Focused history and physical exam
– Complains of trouble breathing.
Airway control w/ adequate ventilation
Oxygenation
– Has a prescribed inhaler available.
Consult medical direction.
Facilitate administration of inhaler
Repeat as indicated.
– Baseline vital signs.
– Reassess
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Treatment with CPAP
CAP Module 2 - CPAP (GHEMS/DG_V2015)
CPAP System
Goal of CPAP
To have an effective way to treat
CHF/Pulmonary Edema
Provide high flow/low pressure oxygenation
Reduce the number of intubations in the field
CAP Module 2 - CPAP (GHEMS/DG_V2015)
CPAP System
The three components of CPAP
Pressure
– The most important component
– Average adult should receive 7.5-10 cmH2O (some
pts. require more…)
– Pressure is the key to CPAP being effective
Flow
– Second in importance
– The more flow, the better…patients want the “windtunnel” in their face.
FiO2
– Least important
– High % of oxygen is not what the CHF pt. needs.
CAP Module 2 - CPAP (GHEMS/DG_V2015)
CPAP System
Two models available
Fixed flow generator
Variable flow generator
CAP Module 2 - CPAP (GHEMS/DG_V2015)
CPAP System
Fixed (GHEMS BLS)
NO knobs to manipulate
Simple
-No Moving Parts
-No flapper valve to restrict flow
Durable
-No maintenance problems
Flow approximately 140 liters/min.
Concentration at 30% FIO2
CAP Module 2 - CPAP (GHEMS/DG_V2015)
CPAP System
Variable (GHEMS ALS)
Three independent controls
On/Off
Flow Rate – up to 140 liters/min.
Highest available
FIO2 – 30% to 100%
Broadest range available
CAP Module 2 - CPAP (GHEMS/DG_V2015)
CPAP System
Patient Circuit
Complete Package includes
1. Mask
2. Tubing
3. Head Strap
4. CPAP Valve
5. Air entrainment filter
CAP Module 2 - CPAP (GHEMS/DG_V2015)
CPAP System
Seal-Flex Mask
1. Comfortable cushion “inflates” with minimal
pressure
2. Leak tolerant - no need for excessive force to
seal mask
3. Anti-asphyxia valve on mask - may be used to
verify proper flow
4. One way valve at base - prevents back flow
5. May be used as a resuscitation mask
CAP Module 2 - CPAP (GHEMS/DG_V2015)
CPAP System
Tubing
7 feet
Has break points
From CPAP Generator to CPAP Valve
Head Strap
3 or 4 point strap
CAP Module 2 - CPAP (GHEMS/DG_V2015)
CPAP System
CPAP Valve
GHEMS…
– 10 cm H2O
– 5 cm H2O
Goes on front of
Mask
Can be “stacked”
CAP Module 2 - CPAP (GHEMS/DG_V2015)
CPAP System
Air entrainment filter
CAP Module 2 - CPAP (GHEMS/DG_V2015)
CPAP System
Oxygen Source
CAP Module 2 - CPAP (GHEMS/DG_V2015)
CPAP System
Low Oxygen Consumption
Fixed uses 13 lpm of oxygen
13 lpm O2 (less than a standard non-rebreather)
127 lpm entrained room air (21% FIO2)
140 lpm total flow
Same flow rate for Variable at initial settings
CAP Module 2 - CPAP (GHEMS/DG_V2015)
CPAP System
Tank Duration
Approximate time at 30% FIO2
D
33 min.
E
50 min.
M
253 min.
H
508 min.
CAP Module 2 - CPAP (GHEMS/DG_V2015)
CPAP System
Two type of CPAP generators
1) Constant Flow
Meets the true definition of Continuous Positive Airway
Pressure
Prevents the need for the patient to initiate flow
Lowers the work of breathing
2) Alternate Flow (Demand Type)
Alternates between positive pressure flow and PEEP
CAP Module 2 - CPAP (GHEMS/DG_V2015)
CPAP System
Advantages of true CPAP
A stable airway pressure as prescribed to reduce the
work of breathing (WOB)
Higher flow rate to ensure continuous positive airway
pressure (140 lpm vs. 100 lpm)
Patient does not have to initiate flow from the device
– Reduces patient anxiety
– Increase patient comfort and compliance
FIO2 from 30% up to 100%
Lower oxygen consumption
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Treatment With CPAP
Indications
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Any patient who is in respiratory distress
with signs and symptoms consistent with:
Congestive Heart Failure (CHF),
Pulmonary Edema,
COPD,
Near Drowning
Other measures to improve oxygenation
and decrease the work of breathing have
failed (i.e., 100% O2 via NRM).
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Treatment With CPAP
Indications (con’t)
– And who is:
Awake and able to follow commands
Is >12 years old and able to fit CPAP mask
Has the ability to maintain an open airway
Exhibits two or more of the following:
–RR > 25 BPM
–SPO2 < 94% at any time
–Use of accessory muscles of breathing
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Treatment With CPAP
Contraindications
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Significant Facial Hair
Patient is apneic
Pneumothorax is suspected
Patient is trauma patient with injury to the chest
Patient has a tracheostomy
Patient is actively vomiting or has upper GI bleeding
Patient has intolerance for CPAP mask or
procedure. (ALS personnel may use Versed 2mg
to 5mg to facilitate patient compliance with
procedure.)
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Treatment With CPAP
Procedure
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EXPLAIN THE PROCEDURE TO THE PATIENT
Place patient on continuous pulse oximetry
Position head of patient at 45 degrees or patient
position of comfort
With device operating, place mask on patient and
secure with straps
Use CPAP valve of 10 cm H2O for most patients
(adult and pediatric). In extreme cases 15 cm H2O
can be utilized.
For variable flow generators Use an initial setting of
30% FiO2 at a flow rate of 140 liters/min., increase
FiO2 PRN.
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Treatment With CPAP
Procedure (cont.)
– Check for air leaks around face/mask interface.
Readjust as needed
– Coach patient to breathe with device
– Request ALS intercept. ALS shall consider
appropriate drug therapy as adjunct
May use small amounts of Versed if the patient does not
tolerate mask.
Use Morphine to reduce preload in CHF patients.
– If respiratory status deteriorates, remove device and
assist ventilations w/ BVM
– ALS personnel should consider intubation (follow RSI
protocol).
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Treatment With CPAP
Patient improvement indicated by:
– Improvement in dyspnea
– Decreased respiratory rate
– Improved pulse oximetry
– Improved patient comfort
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Treatment With CPAP
Removal
– CPAP needs to be continuous and should
not be removed unless the patient cannot
tolerate the mask or experiences respiratory
arrest and/or begins to vomit
– Do not remove CPAP until hospital therapy
is ready
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Treatment With CPAP
Special Considerations
– Watch for gastric distention which can cause
vomiting
– Use extreme caution in patients with endstage COPD: Consider 5 cm H2O as initial
pressure
– CPAP may be used with patients who have
POLST forms or DNR orders
CAP Module 2 - CPAP (GHEMS/DG_V2015)
Thank You
Questions?
CAP Module 2 - CPAP (GHEMS/DG_V2015)