Can CPAP or XPAP be used in a medical emergency?

[Fredman]

Just a dumb thought , but could a CPAP or XPAP be used to assist breathing of a non apnea patient? Would there be enough PSI to get air into the lungs directly.

The pressures we use are to keep the air passages open, not sure how much air would get into the lungs if the brain doesn't signal the diaphragm to assist the lungs in breathing?

Any of you medical folk on CPAPtalk have an opinion...of course Paramedics are my first choice, but I thought to myself if in those 5-10 minutes or longer that it takes to get the Paramedics to your home, your CPAP or XPAP can help with at least keeping the blood sat levels higher...all the better???

[Slinky]

Interesting thought! I hope SAG or one of our other pros sees your post and responds.

I do know that a neighbor probably saved his own life when he experienced a heart attack out in his garage by using a tank of welding oxygen (NOT recommneded! but an emergency IS an emergency!) until the paramedics arrived.

[JeffH]

Interesting thought! I hope SAG or one of our other pros sees your post and responds.

I do know that a neighbor probably saved his own life when he experienced a heart attack out in his garage by using a tank of welding oxygen (NOT recommneded! but an emergency IS an emergency!) until the paramedics arrived.

I worked at a Welding supply store when I was a young'n. The only difference between welding oxygen and medical oxygen is the label on the bottle and the price. They come from the same source and the bottles are filled right next to each other.

[Guest]

Just a dumb thought , but could a CPAP or XPAP be used to assist breathing of a non apnea patient? Would there be enough PSI to get air into the lungs directly.

It is already being used in my area by many local emergency mobile services (ambulances). This started about two years ago.

Rooster

CPAP: An EMT User Guide



By Bob Sullivan, NREMT-P



May 2006, MERGINET—Have you ever found yourself with a patient in respiratory distress who keeps getting worse? The oxygen's cranked as high as it will go and you've given all the drugs that your protocol allows, but your patient can't hold their head up anymore and the hospital just doesn't seem to be getting any closer. The non-rebreather mask or nebulizer just isn't cutting it, and you ask yourself how much worse you'll let your patient get before you intubate them.


CPAP setup.

Fortunately, there is a treatment option available that will help in many of these situations. Continuous positive airway pressure (CPAP) is a non-invasive means of providing respiratory support for patients who are in enough distress that they need more than supplemental oxygen, but are able to maintain a patent airway and do not yet require intubation. By providing a continuous level of pressure to the lungs through an airtight mask, CPAP has been shown to decrease or delay the need for intubation both in the hospital and in the field (Bailey, et al, 2003; Pollack, 2003).



CPAP has been most studied in treating pulmonary edema from congestive heart failure. The increased pressure pushes fluid from the lungs back into the interstitial spaces and then into the pulmonary vasculature, thus increasing the alveolar surface area (Kallio et al, 2003; Kosowsky et al, 2001). CPAP can also be used to treat COPD and asthma exacerbations. It works by keeping collapsing airways open and pushes nebulized medications into constricted bronchioles (Pollack 2003). Even if you are not sure if the patient's distress is caused by COPD or CHF, CPAP should increase oxygenation and decrease their workload to breathe.



So now that your agency has added CPAP to your respiratory distress protocol, how do you use it? CPAP units used in the prehospital setting consist of an oxygen powered generator that connects to a portable or on-board oxygen tank. There is also a kit that contains single patient use items including a bacteria filter, corrugated tubing, mask, head straps and positive-end expiratory pressure (PEEP) valve.



The device works by entraining air from the environment through the bacteria filter and delivers it at a higher pressure to the patient through corrugated tubing and a mask that is sealed to the patient's face. Some units can be adjusted to increase or decrease the amount of pressure while others have fixed settings. The amount of pressure delivered should be set at 5-10 cm/H2O, but should not be set higher than 15 cm/H20. You can start at 5cm/ H20 and titrate up as needed. The percentage of oxygen delivered (FiO2) can be adjusted from about 30 percent to 100 percent, and should also be titrated to meet the needs of the patient based on their skin color, pulse oxymetry and anxiety level. In the interest of saving your oxygen tank's life, however, you should not set the FiO2 higher than needed.



Once you have identified a patient who would benefit from CPAP, first explain to them what you are going to do. Patients who have had CPAP may request it when you arrive at their side but CPAP can also be a frightening experience for those who have never been on it before. Some patients will even try to pull the mask off. Remember that these patients are anxious already from hypoxia. So you must calmly tell them that while they may feel a little uncomfortable at first, they should feel much better in a few minutes. Explain that the sensation is similar to sticking your head out the window of a moving car, and encourage then to inhale through their nose and exhale through their mouth against the pressure. It is very rare for a patient to be unable to tolerate CPAP, but if this occurs it should be removed.



CPAP is contraindicated in patients who do not have an adequate respiratory drive, can not maintain a patent airway, or have a suspected pneumothorax. The most serious potential side effect of CPAP is a pneumothorax, but this has not been demonstrated as a problem (Kosowsky, et al, 2001). Still, you should frequently reassess breath sounds to monitor for this condition.



To apply CPAP, first connect the high pressure tubing to the oxygen source and connect the corrugated tubing to the “outflow to patient” adapter on the generator. Attach the bacteria filter and turn the generator on. Hold the mask up to the patient's face and apply the PEEP valve. The mask should form an air-tight seal, similar to a bag-valve mask, but not too tight. Once the patient gets acclimated to the mask, attach the head straps. The mask can be removed for a few seconds to administer sublingual nitroglycerin, and a nebulizer can be installed in the corrugated tubing.



CPAP generator uses a tremendous amount of oxygen just to deliver the air pressure, and increasing the FiO2 uses even more. At 30 percent FiO2, a D-cylinder will last approximately 30 minutes and an "M" cylinder 250 minutes. At 100 percent FiO2, a D-cylinder will last about three minutes (Lindsey 2003). If the patient can be extricated from their residence quickly it may be best to place them on supplemental oxygen while you move them out and apply CPAP in the ambulance. This creates a Catch-22 situation for patients in high-rise apartment buildings and nursing homes because you want to apply CPAP as early as possible, but not run out of oxygen waiting for the nursing home elevator during meal time.



What I've found works well is to move the patient onto the stretcher and apply it just before leaving the room or apartment. CPAP is not difficult to operate and can be used by providers at all levels. It is helpful to have two providers who are competent in using it to ride with the patient; one to apply CPAP and adjust the settings and the other to do anything else needed for the patient.



Once CPAP is initiated, it should be continued in the hospital, so it is important for agencies that begin using it to work with their receiving hospitals. The hospital should be notified as soon as possible so that they can have their equipment ready. Remember that you will need some oxygen in a spare tank for when you get to the hospital, so you should have some extra tanks accessible. When transferring the patient to another tank, you must remove the PEEP valve.



CPAP therapy can help avoid the need for intubation. However, it does not replace intubation or any other therapies currently used to treat respiratory distress. Think of it as a means of alleviating symptoms while medications work to correct the underlying problem. Some patients will continue to deteriorate despite CPAP and intubation may still be necessary.



Using CPAP when appropriate is a safe and effective treatment option. With a little practice, it is easy to use and will help many patients quickly feel better.



References

Bailey P. Sweeney T, et al. “Prehospital CPAP reduces the need for endotracheal intubation, Poster Presentation,” Prehospital Emergency Care. 2003;7:166.



Kallio T. Kuisma M, et al. “The use of prehospital continuous positive airway pressure treatment in presumed acute severe pulmonary edema.” Prehospital Emergency Care. 2003; 7:209-213.



Kosowsky J. Stephanides S, et al. “Prehospital use of continuous positive airway pressure (CPAP) for presumed pulmonary edema: A preliminary case series.” Prehospital Emergency Care. 2001; 5:190-196.



Pollack C. “Noninvasive ventilatory support in the emergency department.” Manual of Emergency Airway Management . Philadelphia: Lippincott, Williams, and Wilkins, 2000.

Source: http://www.merginet.com/index.cfm?pg=airway&fn=CPAPuser

[Fredman]

Thanks Rooster! Your wealth of information.

[mfbower]

We currently carry a CPAP machine on every ambulance. In the state of Virginia (or at least my county), only an ALS person (that's Advanced Life Support) can use them. EMT-B's cannot. EMT-E through EMT-P can use them.

[Fredman]

We currently carry a CPAP machine on every ambulance. In the state of Virginia (or at least my county), only an ALS person (that's Advanced Life Support) can use them. EMT-B's cannot. EMT-E through EMT-P can use them.

That's good to know, I'd imgine, generally across the US and Canada that this is becoming common equipment on board?

An earlier thread about wearing Medical Emergency bracelet or dog tags to advise medical personnel that the wearer has sleep apnea, then is critical for emergency treatment employed by Paramedics....soooo I guess we should be wearing a medic-alert (available in Canada) identification.

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