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Title: Rama


1
Rama Beausoleil CPAP CME 2009
2
Agenda
  • Welcome housekeeping
  • CPAP didactic review
  • Break
  • Skills
  • CPAP MACS
  • Scenarios
  • KAT
  • Course evaluation

3
Prehospital CPAP
Reviewed by MAC May 2008
4
Acknowledgements
REVIEWERS/CONTRIBUTORS Dr. Sheldon Cheskes,
MD SOCPC Ted Reesor, RRT Tim Dodd, AEMCA,
ACP Chair, OBHG Education Subcommittee Hamilton
Base Hospital Maud Huiskamp, AEMCA,
ACP SOCPC
AUTHOR Cathie Hedges, ACP Essex Kent
(Windsor) Base Hospital
2008 Ontario Base Hospital Group
5
Objectives
  • Anatomy overview
  • O2 saturation monitoring
  • Positive End Expiratory Pressure (PEEP)
  • Continuous Positive Airway Pressure (CPAP)

6
Respiratory System
  • UPPER RESPIRATORY TRACT
  • Oro/nasopharynx
  • Larynx
  • Trachea to the carina

What is the major function of these structures?
Warms, Filters Humidifies
7
Respiratory System
  • LOWER
  • RESPIRATORY
  • TRACT
  • Trachea
  • Bronchi
  • Bronchioles
  • Alveoli

Whats the main occurrence here?
Gas exchange!
8
Lungs
Where does gas exchange occur?
Where the Circulatory and Respiratory Systems
join together
9
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

10
The Act of Breathing ..
  • INSPIRATION
  • Diaphragm
  • Intercostal muscles
  • Creates a negative pressure in the lungs
    (alveoli) compared to the atmosphere
  • Atmospheric air rushes in to fill the void
  • Gas exchange occurs by diffusion.

contracts (drops)
contract (ribs go up out)
11
Mechanics of Ventilation
  • Exhalation
  • ? Thoracic Cage
  • Passive Process
  • Inspiration
  • ? Thoracic Cage
  • ? 3 mmHg Alveolar Pressure

12
Oxygen Saturation
  • Pulse oximetry is a tool used to monitor the
    effectiveness of the patients respiratory status
    so treatment can ensure that adequate and
    effective oxygenation is maintained.

13
Why use O2 Sat monitors?
  • Does the physical assessment alone provide an
    adequate picture for good oxygen saturation?

Hypoxemia may not be evident until oxygen
saturation levels are quite low
For example cyanosis to lips, nail beds, ear lobes
14
Pulse Oximetry Review
  • Pulse oximeters consist of a sensor containing a
    light source and a photodetector.
  • Technology based on a colour spectograph the
    photodetector determines the light absorbed while
    passing through the capillaries then displays
    the calculated saturation levels.
  • .How can it be fooled?

15
Factors affecting Oximetry
  • Strong ambient light sources
  • Poor circulation
  • Cardiac arrest
  • Hypothermia
  • Shock
  • Anemia
  • CO poisoning
  • Nail polish

16
Plethograph
  • Also know as the O2 sat waveform
  • If the waveform is the same with each pulse, then
    the numeric value will be accurate.

17
Take Home Points
  • Oxygen saturation may be utilized to monitor a
    patients condition
  • Do not restrict oxygen delivery based on
    numerical values.
  • Remember to treat the patient not the monitor.
    If the patient appears ill and you feel oxygen
    will benefit the patient, give oxygen! -
  • It grows on trees!!

18
What is PEEP? Positive End Expiratory Pressure
  • Mechanically maintaining airway pressure above
    atmospheric pressure at the end of exhalation.
  • Decreases the shunting of blood through the lungs
    and improves gas exchange.
  • PEEP is done in ARDS (acute respiratory distress
    syndrome) to allow reduction in the level of
    oxygen being given.
  • The equivalent in a spontaneously breathing
    patient is

19
CPAP
  • ontinuous
  • ositive
  • irway
  • ressure

C P A P
20
CPAP Learning Objectives
  • History of CPAP
  • Goal of CPAP in the field
  • CPAP and its physiological effects
  • Medical applications of CPAP
  • CPAP Medical Directive
  • Contraindications CPAP
  • Delivery Systems

21
History of CPAP
  • 1912 - Maintenance of lung expansion during
    thoracic surgery (S. Brunnel)
  • 1937 - High altitude flying to prevent hypoxemia.
    (Barach et al)
  • 1967 - CPPB IPPV to treat ARDS
    (Ashbaugh et al)
  • 1971 - Term CPAP introduced, used to treat HMD in
    neonates (Gregory et al)
  • 1972 - CPAP used to treat ARF
    (Civetta et al)
  • 1973 - CPAP used to treat COPD
    (Barach et al)
  • 1981 - Downs generator
    (Fried et al)
  • 1982 - Modern definition of CPAP
    (Kielty et al)
  • 1992 CPAP to spontaneously breathing patients
    (Keilty et al)

22
Some Facts
  • The Aging Patient Population is increasing
    dramatically as Baby Boomers are reaching
    retirement age
  • Multiple factors (diet, lack of exercise, etc)
    are causing a surge in cardiac and respiratory
    problems
  • The Canadian Heart and Stroke Foundation reports
  • Heart failure is on the increase as a result of
    successes in treating heart attacks and other
    cardiac conditions
  • It is estimated that there are 400,000 Canadians
    living with congestive heart failure (CHF).
  • Up to 40 to 50 of people with congestive heart
    failure die within five years of diagnosis.

12/26/2009
22
23
Some More Facts
  • CPAP provides an adjunct between oxygen by NRB
    and Endotracheal Intubation
  • Reduces days in hospital without a reduction in
    quality of care
  • Reduces trauma infection risks associated with
    intubation
  • Of those with ventilator acquired pneumonia 50
    will die CPAP may help avoid the ventilator
    greatly reducing this risk!!
  • (Implementation of Guidelines on
    hospital-acquired pneumonia. Torres, Antoni. 128,
    Barcelona, Spain  Chest, 2005. 1900-1802.)

12/26/2009
23
24
Goal of Prehospital CPAP
  • Provide an effective way to
  • treat CHF/COPD by
  • Increasing Functional Residual Capacity (FRC) -
    volume of gas remaining in lungs at
    end-expiration
  • Distending alveoli preventing collapse on
    expiration and providing a greater surface area
    improving gas exchange

25
How Does CPAP Work?
  • A tight fitting mask controlled by a regulator
    designed to provide a high flow of variable or
    fixed oxygen concentration.
  • Most important feature is a flow restriction
    device at the exhalation port of the mask, which
    works the same way as Positive End Expiratory
    Pressure (PEEP).
  • Places the patients airways under a constant
    level of pressure throughout the respiratory
    cycle, causing fluid and other obstructions to be
    "pushed" back where they belong.

12/26/2009
25
26
How Does CPAP Work?
  • Splints the airways open, increasing potential
    for gas exchange
  • Increases surface area of the alveoli,
    increasing potential for gas exchange.
  • Decreases the work of the heart by increasing
    oxygenation.

12/26/2009
26
27
Before CPAP treatment
Decreased area for gas exchange
After treatment with CPAP ? venous return and
filling pressures ? compliance ? effective
ventilation ? work of breathing
Increased surface area for gas exchange
12/26/2009
27
28
What Is good PEEP/CPAP?
  • Fully inflated alveoli
  • Even surface area

29
What Is Bad PEEP/CPAP?
  • Unevenly shaped alveoli
  • Collapsing
  • Resulting in decrease of surface area

30
Good versus Bad
31
CPAP and Airway Pressure
The application of positive airway pressure
throughout the respiratory cycle to spontaneously
breathing patients.
32
CPAP Reopens Collapsed Airway
  • Acts a pneumatic stent i.e.
  • Soft palate collapse in obstructive sleep apnea
    (nocturnal CPAP for home use)
  • Bronchial collapse (COPD) causing air trapping in
    alveoli
  • Alveolar collapse from surfactant washout with
    pulmonary edema
  • Each of the above applications increases the
  • amount of air left in the lungs after exhalation
    (FRC) by opening blocked passages.

33
CPAP and Partial Pressure
  • The pressure of a gas mixture is equal to the
    sum
  • of the partial pressures of its constituents.
  • This allows oxygen into the blood during
    inspiration
  • and Carbon Dioxide out during expiration.
  • Example Air at sea level has a pressure of
  • 760mm Hg.
  • Air is 21 oxygen and 79 nitrogen.
  • Partial pressure of oxygen at sea level is
  • 760 X 21 159mm Hg

34
CPAP and Partial Pressure
  • Remembering air is 21 oxygen and 79
    nitrogen, and at sea level has a pressure of
    760mm Hg, what is the partial pressure of
    nitrogen at sea level?
  • 760 X 79 600 mmHg

35
Pressure Gradient
So why does oxygen pass into the blood?
  • Deoxygenated blood has a lower partial pressure
    of oxygen than alveolar air so oxygen transfers
    from the air into the blood.

36
7.5cm H20 CPAP
CPAP alters the pressure gradient!
  • 1cm H2O is equal to 0.735mm Hg.
  • 7.5cm H2O CPAP increases the partial pressure
  • of the alveolar air by approximately 1.
  • This increase in partial pressure forces more
  • oxygen into the blood.
  • Even this comparatively small change is enough
  • to make a clinical difference.

37
Advantages of CPAP
  • Flexibility in initiating, interrupting, and
    discontinuing mechanical ventilation
  • Decreases the need for ICU admission
  • Improves patient comfort
  • Psychological advantage to the patient
  • Preserves speech and swallowing, allowing patient
    to communicate with family and staff

12/26/2009
37
38
CPAP versus ETT versus PPV
  • CPAP
  • Non-invasive
  • Easily discontinued
  • Easily adjusted
  • Does not require sedation
  • Comfortable
  • Intubation
  • Invasive
  • Potential for infection
  • Requires highly trained personnel
  • Can require sedation
  • Traumatic for the patient
  • PPV
  • Non-invasive
  • Easily discontinued
  • Difficult to monitor
  • Does not require sedation
  • Comfortable
  • A clinical decision should be made based on the
    severity and condition of the patient and
    whether intubation is necessary
  • CPAP requires the patient to be awake,
    spontaneously breathing and able to maintain an
    open airway

12/26/2009
38
39
Acute Pulmonary Edema versus CHF
  • There could be crackles on auscultation for both,
    why do I need to know the difference?

40
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41
Assessment Treatment
  • A Assess and control airway.
  • Patient positioning
  • B Assess breathing.
  • Give O2 PPV
  • SpO2
  • C Assess circulation
  • Cardiac monitor
  • 12 Lead ECG PRN
  • Pulse (location)
  • BP
  • JVD
  • Gain IV access
  • NTG as per medical directive
  • CPAP as per medical directive

42
Ventolin and CHF?!
  • Drug classification?
  • How does it work on the CV system?
  • Is it a good thing to give Ventolin if the
    patient has wheezing when suffering from CHF or
    APE?

43
CPAP And Pulmonary Edema
  • Severe pulmonary edema is a frequent cause of
    respiratory failure
  • CPAP increases functional residual capacity
  • CPAP increases transpulmonary pressure
  • CPAP improves lung compliance
  • CPAP improves arterial blood oxygenation
  • CPAP redistributes extravascular lung water
  • (Rasanen 1985)

44
Redistribution Of Extravascular Lung Water With
CPAP
CPAP And Pulmonary Edema
45
Define COPD
  • Chronic Obstructive Pulmonary Disease
  • Any disorder that persistently obstructs
    bronchial airflow.
  • COPD mainly involves two related diseases --
    chronic bronchitis and emphysema.
  • The obstruction is generally permanent and
    progresses over time.
  • ASTHMA IS NOT COPD

46
CPAP And COPD
  • CPAP overcomes inspiratory work imposed by
    auto-peep
  • CPAP prevents airway collapse during exhalation
  • CPAP improves arterial blood gas values
  • CPAP may avoid intubation and mechanical
    ventilation
  • (Miro 1993)

47
CPAP Common Complications
  • Pressure sores
  • Gastric distension
  • Pulmonary barotrauma
  • Reduced cardiac output
  • Hypoventilation
  • Fluid retention

48
Medical Directive
  • Indications
  • Patient is awake and able to follow commands in
    moderate to severe respiratory distress as
    evidenced by two of three of the following
  • Respiratory rate gt24 breaths per minute
  • SpO2 of lt 90 at any time
  • Accessory muscle use

49
Medical Directive
  • Indications (continued)
  • AND with signs and symptoms consistent with
  • exacerbation of chronic obstructive pulmonary
    disease (COPD),
  • acute pulmonary edema, OR
  • acute congestive heart failure (CHF)

50
Medical Directive Absolute Contraindications
  • Pt unable to cooperate
  • Suspected pneumothorax
  • Major trauma/burns (face, neck, chest/abdomen)
  • Unable to sit upright
  • Facial anomalies
  • Tracheostomy
  • Intubated patient
  • Resp rate lt 8
  • Systolic BP lt 90
  • Age lt 12 or lt 40 kg
  • Decreased mentation
  • Potential airway compromise i.e. Vomiting, FBO,
    GI bleed
  • Cardiac arrest

51
Documentation
  • ACR special equipment code 63

Document on the ACR Code 339 each time you
adjust the CPAP settings Reassessments are
documented every 5 minutes Code 010 Vital Signs
Code 336 Respiratory evaluation
52
When do I bring the CPAP device to a call?
  • All calls with a complaint of SOB
  • All calls with a complaint of CP

53
How do I titrate CPAP to effect?
  • Titration what is that?
  • Is the process of gradually adjusting the dose
    until the desired effect is achieved.
  • Titration criteria
  • Clinically no improvement in respiratory
    distress
  • Respiratory rate
  • Work of breathing
  • Use of accessory muscles
  • Lack of improvement in SpO2

54
Titration to effect
  • Increase CPAP by 2.5 cm H2O
    Q 5 minutes when
  • No clinical improvement
  • To a maximum of 15 cm H2O
  • Increase FIO2 to 100 when
  • SpO2 remains below 90 during treatment OR
  • If no clinical improvement at 10 cm H2O CPAP
  • Clinical improvement
  • No changes in CPAP
  • No changes in FIO2

55
Discontinue use
  • When the patient cannot tolerate the mask after
    coaching
  • Patient begins to vomit
  • Patient experiences a respiratory rate lt8
  • PPV with BVM or endotracheal intubation should be
    considered if the patient is removed from CPAP
    therapy
  • Treat the circuit as medical waste

56
MACS CPAP device
57
Program Objectives
  • Describe the main operating features of MACS
  • Identify the controls and connections
  • Describe the patient circuit
  • Set-up MACS for patient operation
  • Clean and maintain the MACS

58
Features and Controls Rear Panel
  • Driving Gas Input
  • Connection for 50 psi oxygen source gas
  • Always use a high flow gas source (pressure
    take-off) that can provide 55 15 psi pressure
    at a minimum of 40 L/min

59
Features and Controls Rear Panel
  • Air Entrainment
  • Ambient air is entrained for internal gas mixing
  • External housing contains air filter
  • Air filter replacement is part of the
    preventative maintenance

60
Features and Controls Front Panel
  • CPAP Control
  • Adjusts the CPAP from 0 to 20 cm H2O
  • Automatic sensitivity
  • Flow adjusts automatically to meet patient demand
    up to 140 L/min
  • Oxygen concentration is maintained at set
    Oxygen control

61
Features and Controls Front Panel
  • Oxygen Control
  • Delivered oxygen choice
  • 65
  • 100
  • Sets the spontaneous breath oxygen concentration

62
Features and Controls Front Panel
  • Pressure Gauge
  • Shows pressure in patient circuit at the output
    of MACS
  • Gives an indication of patient effort

63
Features and Controls Front Panel
  • Circuit Connection 1
  • Connection for the large bore hose of the
    patient circuit

64
Features and Controls Front Panel
  • Circuit Connection 2
  • Patient circuit small hose connection
  • Connects to the expiratory valve on the patient
    circuit

65
Patient Circuit
  • Patient circuit is a disposable, single limb
    system
  • Both hoses attach to the front of MACS
  • Patient end connects for clinical intervention
  • Resuscitator face mask (noninvasive)

66
Patient circuit
  • Circuits will need to be assembled with 2 filters
    for personnel and patient safety

67
Patient Application
  • Initial Set-up
  • Attach a high pressure oxygen hose to the rear of
    MACS
  • Attach this hose to the oxygen source
  • Attach the circuit to the front of the MACS

68
Patient Application
  • Set Oxygen Control
  • Set Oxygen control to 65
  • All breaths receive set oxygen level 10
  • Oxygen tank time doubles with 65
  • Caution - with rapid, large tidal volumes on 100
    oxygen, the actual delivered percentage might be
    slightly less than 100

69
Approximate operating time using a full D tank
Based on 10cm of water CPAP
70
Apply mask to the patient
  • Carefully explain the procedure to the patient
  • Size the mask (one size fits most)
  • Harness may be applied to one side prior to
    application
  • Hold the mask in place while coaching the patient
  • Tell the patient that you are going to secure the
    mask
  • Secure and adjust the head straps once the
    patient is accepting the mask
  • One strap above the ear
  • One strap below the ear

71
Mask application
72
What about.
  • Facial hair?
  • You may need to adjust the mask a little more
    tightly
  • Dentures?
  • Put teeth in for a better mask fit
  • Air leak?
  • Minor leak, leave as is. You do NOT need a tight
    seal, the mask needs to fit properly and
    comfortably. MACS is not a closed system and does
    not require a tight seal.
  • Major leak, you will see frequent blinking of the
    patient. Adjust the BOTTOM straps to improve the
    fit
  • Mask size?
  • The mask is designed to fit on the face or
    underneath the chin to accommodate patients of
    many sizes.

73
Patient Application
  • Start CPAP
  • Turn on oxygen source
  • Attach patient breathing circuit to the patient
  • Adjust the CPAP control to the level desired up
    to a max 15 cm H2O
  • If the patient is not attached to the circuit, or
    there is a large leak, a high flow of gas will
    occur
  • The machine will leak compensate

74
Patient Application
  • Monitor patient
  • Reassess Q 5 minutes
  • Reassess response to treatment
  • vital signs
  • O2 Sat
  • Document your findings

75
Patient monitoring LP12
76
NTG administration as per medical directive
  • The mask may be removed for a short time to
    administer NTG as indicated.
  • Have the patient hold the mask, remove the
    straps, administer NTG, hold the mask, and apply
    the straps.
  • As tolerated by the patient.

77
MDI Ventolin administrationas per medical
directive
  • An MDI adapter may be placed between the 90º
    elbow and the mask.
  • Coordinate the administration of each dose with
    the patients inhalation.

78
CPAP switching O2 sources
  • When transferring oxygen sources from the
    portable D tank to the ambulance then to the
    hospital source, make the transition as quickly
    as possible so as not to lose too much positive
    pressure.

79
Patient Safety Features
  • Internal Safety Pressure Release limits circuit
    pressure to 40 cm H2O
  • Anti-Suffocation System in the event of device
    malfunction, an internal valve will allow ambient
    air to enter the patient circuit

80
Cleaning and Maintenance
  • Clean MACS between patients using a soft cloth
    and a mild detergent / disinfectant
  • Do not immerse MACS in water
  • Patient circuit is disposable, single use
    application and should not be cleaned,
    disinfected or reused
  • MACS should receive preventative maintenance
    every 2 years
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