CPAP For ALS & BLS

1. CAP – Module 2 CPAP For ALS & BLS CAP Module 2 - CPAP (GHEMS/DG_V2015)

2. 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)

3. 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)

4. 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)

5. 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)

6. CPAP 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 CPAP vs. Intubation CAP Module 2 - CPAP (GHEMS/DG_V2015)

7. Review of Anatomy & Physiology CAP Module 2 - CPAP (GHEMS/DG_V2015)

8. UPPER AIRWAY Nares Nasopharynx Oropharynx Tongue Epiglottis/Glottis Vocal Cords LOWER AIRWAY Trachea/Esophagus Carina Main stem Bronchi Secondary Bronchi Bronchioles Alveoli Elements of the Airway CAP Module 2 - CPAP (GHEMS/DG_V2015)

9. Upper Airway CAP Module 2 - CPAP (GHEMS/DG_V2015)

10. 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)

11. 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)

12. 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)

13. Lower Airway CAP Module 2 - CPAP (GHEMS/DG_V2015)

14. CAP Module 2 - CPAP (GHEMS/DG_V2015)

15. 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)

16. Pleural Cavity • A separate pleural cavity surrounds each lung • Two layers (visceral and parietal) • Pleural space CAP Module 2 - CPAP (GHEMS/DG_V2015)

17. 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)

18. Respiratory System - Physiology • Wastes, including carbon dioxide, are excreted from the body via the respiratory system CAP Module 2 - CPAP (GHEMS/DG_V2015)

19. 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)

20. 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)

21. Pressure Changes During Inspiration and Expiration CAP Module 2 - CPAP (GHEMS/DG_V2015)

22. Mechanics of Breathing CAP Module 2 - CPAP (GHEMS/DG_V2015)

23. Mechanics of Respiration CAP Module 2 - CPAP (GHEMS/DG_V2015)

24. 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)

25. 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)

26. 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)

27. 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)

28. 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)

29. 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)

30. Review of Respiratory Distress CAP Module 2 - CPAP (GHEMS/DG_V2015)

31. 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)

32. 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)

33. History • Previous experiences with similar/identical symptoms • Known pulmonary diagnosis • Medication history • 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)

34. Secondary Assessment 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)

35. 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)

36. 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)

37. 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)

38. 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)

39. Chronic Obstructive Pulmonary Disease (COPD) • Signs/Symptoms/Assessment • 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)

40. Chronic Obstructive Pulmonary Disease (COPD) • Signs/Symptoms/Assessment • Tachypnea, cyanosis, agitation, tachycardia, hypertension • Confusion, tremor, stupor, apnea CAP Module 2 - CPAP (GHEMS/DG_V2015)

41. 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)

42. 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)

43. 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)

44. 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)

45. 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)

46. 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)

47. 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)

48. Treatment with CPAP CAP Module 2 - CPAP (GHEMS/DG_V2015)

49. 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)

50. 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 “wind-tunnel” in their face. • FiO2 • Least important • High % of oxygen is not what the CHF pt. needs. CAP Module 2 - CPAP (GHEMS/DG_V2015)