Virginia Beach EMS

Oxy-PEEP C-PAP
Eric de Forest, NREMT-P

C-PAP Overview
? Applies continuous pressure to airways

to improve oxygenation. ? Bridge device to improve oxygenation until underlying cause of the respiratory distress can be treated.

With any new subject, youve got to learn the lingo

? NIPPV ? NIPSV ? C-PAP ? Bi-PAP ? I-PAP ? E-PAP ? PEEP ? FiO2

With any new subject, youve got to learn the lingo

? NIPPV

Non-invasive positive pressure ventilation ? NIPSV Non-invasive pressure support ventilation

With any new subject, youve got to learn the lingo

? C-PAP

Continuous positive airway pressure ? Bi-PAP Bi-level positive airway pressure ? I-PAP Inspiratory positive airway pressure ? E-PAP Expiratory positive airway pressure

With any new subject, youve got to learn the lingo

? PEEP Positive

end-expiratory pressure ? FiO2 Fraction of inspired air

C-PAP vs. PEEP

? C-PAP

non-invasive ? PEEP for intubated patients ? Terms used interchangeably

C-PAP vs. Bi-PAP

? C-PAP

Continuous pressure 5-20 cm H2O

? Bi-PAP

Alternating pressure More with inspiration 10 cm H2O Less with expiration 5 cm H2O

Upper Airway
? Mouth/Nose ? Oro/Nasopharynx ? Pharynx ? Epiglottis

Lower Airway
? Larynx ? Trachea ? Main

Bronchi (R/L) ? Bronchioles ? Alveoli

Alveolar Capillary Beds

Normal Breathing
? Muscles

Diaphragm Accessory Muscles

Inspiration

Expiration

Control of Breathing
? CO2 Level

in Arterial Blood Drive

? Hypoxic

Gas Exchange
? Ventilation ? Diffusion ? Perfusion

Ventilation

Diffusion

Perfusion

Congestive Heart Failure

? Left

Ventricular failure causes blood to back up

Pulmonary circulation (capillary beds) Interstitial tissues Alveoli

Congestive Heart Failure

? Pulmonary

edema interferes with oxygen crossing alveolar/capillary membrane

Congestive Heart Failure

? Pulmonary

edema washes out surfactant

Increased work of breathing to maintain open alveoli

CHF
? Bilateral

Infection
rales or
? Uni-lateral

rales or

crackles ? Clear or pink sputum

crackles ? Fever ? Productive cough with green/yellow sputum

COPD
? Chronic Obstructive Pulmonary Disease

Emphysema Chronic Bronchitis Asthma

Emphysema
? Loss

of elasticity of lung tissue

Difficulty exhaling
Air trapping CO2 retention

? Break

down of alveolar walls

Decrease surface area for gas exchange

Chronic Bronchitis
? Chronic

Inflammation of bronchiole tree with increased mucous production ? Difficulty exhaling

Air trapping CO2 retention

Asthma
? Intermittent

Bronchoconstriction ? Difficulty exhaling

Air trapping CO2 retention

Physiological Benefits of C-PAP

? Increase in alveolar pressure

Stop fluid movement into alveoli Improves gas distribution Prevents alveolar collapse Improves re-expansion of alveoli
? Reduces work

of breathing ? Reduces respiratory muscle fatigue

Physiological Benefits of C-PAP

? Increases intrathoracic pressure

Improves cardiac output to a point Too much PEEP decreases cardiac output
? Decreases need for intubation and

associated complications

Hazards/Complications of C-PAP
? Airway

Mask impairs access to patients airway C-PAP does not ventilate the patient Gastric distension / vomiting
Aerophagia (swallowing air) sensitive patients
Gastric stapling Upper GI surgery

Hazards/Complications of C-PAP
? Hypoxia

Loss of oxygen supply

Empty oxygen tank Disconnection of Oxy-PEEP from oxygen source

Mask Leak Rebound hypoxia may be more severe than initial hypoxia

Calculate Oxygen Duration

(Tank PSI safe residual) X cylinder constant = minutes LPM

Portable Cylinders
Cylinder Flow D 15 LPM D 25 LPM E 15 LPM E 25 LPM 1000 PSI 8.5 min 5.1 min 14.9 min 9 min 1500 PSI 13.8 min 8.3 min 24.3 min 14.6 min 2000 PSI 19.2 min 11.5 min 33.6 min 20.2 min

Calculate Oxygen Duration

(Tank PSI safe residual) X cylinder constant = minutes LPM

Main Cylinders
Cylinder Flow M 15 LPM M 25 LPM G 15 LPM G 25 LPM 500 PSI 31 min 18 min 48 min 29 min 1000 PSI 83 min 50 min 129 min 77 min 1500 PSI 135 min 81 min 209 min 125 min

Hazards/Complications of C-PAP
? Hypotension

Increased intrathoracic pressure causes

Decreased venous return Decreased cardiac output

Increased pulmonary pressure causes

Decreased blood flow through pulmonary vessels Decreased cardiac output

Hazards/Complications of C-PAP
? Barotrauma

High alveolar pressures can cause over-inflation of lung resulting in

Pneumothorax Pneumomediastinum

Concerns using C-PAP with COPD

? Increased

Air

Trapping ? Hypotension ? Barotrauma

Hazards/Complications of C-PAP
? More

PEEP is NOT necessarily better

Hazards/Complications of C-PAP
? More

PEEP is NOT necessarily better

If 5 cm H2O PEEP is good it DOES NOT mean that 10 cm H2O is better!!! Most patients will respond to 5 cm H2O PEEP

Hazards/Complications of C-PAP
? Patient Discomfort

Requires patient cooperation to tolerate a tightly fitting mask

Sensation of smothering or claustrophobia

Use trial to introduce patient to device prior to securing head strap Consider sedation for extreme anxiety with orders from Medical Control

Oxy-PEEP C-PAP
? Equipment

Mask FiO2 dial Reservoir bag Air intake valve PEEP valve Head strap

Mask

FiO2 Dial
? Range ? LPM

32-95%

Minimum 15 LPM Maximum: flush (25 LPM)

FiO2 dial
? Initial

application Set at 95%

FiO2 dial

Reservoir Bag
? Fill

before applying C-PAP to patient ? Self-fills at FiO2 95%

Air Intake Valve

? At

lower FiO2, allows room air to be drawn into system ? C-PAP benefits primarily come from pressure not oxygen concentration

PEEP Valve
? Range

5-20 cmH2O ? PEEP valve accurate +/- 2cm H2O

Manufacturer recommends checking against manometer pressure gauge

PEEP Valve
? Factory

setting less than 5 cm H2O ? Verify that cap turn easily but will hold its setting ? Turn cap so bottom edge is on desired setting
Initial 5 cm H2O

Head Strap
? Apply

to patients head after patient accepts C-PAP

Patient Criteria to Use Oxy-PEEP

? Old

enough to get adequate mask seal

Recommended for patients 18 years or older

? Alert

with intact airway and ventilatory

drive ? Systolic BP at least 90 mmHg

Patient Criteria to Use Oxy-PEEP

? Sudden

onset of respiratory distress from pulmonary edema. S/S include

Anxiety/restlessness Dyspnea with s/s hypoxia
Verbal complaint 1-2 word dyspnea Accessory muscle use Tachypnea Tachycardia Pallor (pale) Cyanosis Diaphoresis

Patient Criteria to Use Oxy-PEEP

? Frothy

sputum (may be pink) ? Room air SpO2 < 94% ? Bilateral crackles / rales ? Peripheral edema ? Chest pain

Absolute Contraindications
? Inadequate

airway or respiratory drive

Absolute Contraindications
? Need

for immediate airway control (intubation)

Absolute Contraindications
? Hemodynamic

instability
Systolic BP <90 mmHg

Absolute Contraindications
? Aspiration

risk

Vomiting or severe nausea

Relative Contraindications
? Upper

airway or facial abnormalities or trauma that interfere with mask seal

Relative Contraindications
? Uncooperative

patient

Relative Contraindications
? Respiratory distress caused by

Aspiration Asthma (requires MD orders) COPD (requires MD orders) Pneumonia Pneumothorax Anaphylaxis Pulmonary embolism Respiratory Burns

Procedure
? Assess patient for S/S pulmonary

edema ? Room Air SpO2 < 94% ? Systolic BP at least 90 mmHg

Procedure
? Implement

CHF branch of Difficulty Breathing

protocol ? May be done simultaneously with application of C-PAP

High flow O2 via NRB until C-PAP applied Monitor / IV Nitroglycerin 0.4 mg SL X3
Once C-PAP applied, unfasten mask to administer Ntg

Lasix 40 mg IV Albuterol HHN if wheezing Morphine 2-4 mg slow IV every 5 minutes up to 10 mg total

Procedure
? Prepare C-PAP

Equipment

Adjust FiO2 to 95% Set PEEP at 5 cm H2O Set O2 flow at flush (minimum 15 LPM) Fill reservoir bag Prepare intubation equipment Ensure adequate supply of oxygen (main and portable)

Procedure
? Prepare Patient

Position Stretcher at 45 degrees or higher Inform patient of procedure

Procedure
? Mask Application

Trial to introduce device

Explain patient will feel positive oxygen pressure

Hold mask gently on patients face ensuring good seal Once patient accepts mask, secure mask with straps Deflate mask as needed to get good seal

Procedure
? On-Going

Care / Monitoring

Reassess at least every 5 minutes

Patients impression of difficulty breathing Vital signs Lung sounds SpO2

Observe for complications

Hypotension Barotrauma Worsening dyspnea

Procedure
? If

patient continues to have severe difficulty breathing after 5 minutes, consider increasing PEEP to 10 cm H2O
Systolic BP must be at least 90 mmHg CAREFULLY watch for complications of increased PEEP

Procedure
? On-Going

Care / Monitoring

Oxygen conservation
If patient is improved with C-PAP
SpO2 > 94% Work of breathing improved

Consider decreasing LPM to 15 Make sure reservoir bag remains full Carefully monitor patient status including SpO2

Discontinuing C-PAP
? C-PAP

usually is not discontinued in the

field ? High PEEP level may require weaning ? Rebound hypoxia can be worse than initial hypoxia

Discontinuing C-PAP
? Patient

requires BVM or intubation

Remove C-PAP, ventilate and intubate

Discontinuing C-PAP
? Need to suction airway

Remove C-PAP, suction, reapply C-PAP

Discontinuing C-PAP
? BP

drops below 90 mmHG Contact Medical Control

Is High PEEP worsening patients condition? OR Is the underlying pathology causing the deterioration?

Discontinuing C-PAP
? Consider decreasing PEEP with

orders

from Medical Control

Patient hemodynamically stable at 5 cm H2O PEEP PEEP increased to 10 cm H2O and BP dropped Is High PEEP worsening patients condition or is the underlying pathology causing hypotension?

Protocol Use
? Included

in A/O/V and Difficulty Breathing Protocols ? Standing order for CT/I/P to use for CHF induced pulmonary edema

Protocol Use
? Initial

PEEP 5 cm H2O ? FiO2 95% ? Standing order to increase to 10 cm H2O if patient in severe distress and not improving after 5 minutes
Most patients will respond to 5 cm H2O PEEP

Documentation It IS Your Job

Documentation
? Document

Use under Other

Not positive pressure ventilation

Documentation - Narrative
? Patients

S/S including SpO2 ? S/S indicating CHF vs. COPD to rule in C-PAP use
C-PAP use for COPD requires orders from Medical Control
? C-PAP settings

FiO2 PEEP O2 LPM Any changes in settings and why

Documentation
? Treatments

to correct underlying pathology ? Patients response to C-PAP and other treatments

Questions????
- D. Brennaman: Initial Author