Continuous Positive

Airway Pressure

For EMT Providers

State Education & Training Committee

December 2012
 Goal
 The student will be able
to correctly utilize
service specific CPAP
devices in a respiratory
compromised patient

 [img]http://hammondems.com/images/d_1976.jpg
 Objectives
 At the completion of this training, the BLS
provider will:
 Describe respiratory anatomy and physiology
 Verbalize understanding of respiratory
disorders / illnesses
 Appreciate the benefits and limitations of
CPAP in alleviating patient symptoms
 List indication and contraindications for use.
Anatomy and Physiology
of Respiration
Respiratory Physiology

 Nose / Mouth
 Trachea
 Mainstem Bronchi
 Secondary Bronchi
 Tertiary Bronchi
 Bronchioles
 Terminal Bronchiole
 Alveoli
 Diaphragm

 http://www.uni.edu/schneidj/webquests/spring04/offtowar/respiratory.html
 Negative Pressure
 Respiration driven by process of negative
intrathoracic pressures
 Negative pressure
 Initiates inhalation and acquisition of O 2
 Assists to increase intrathoracic blood flow

 Hemodynamic Effects

 Equalization of pressures
 initiates exhalation and elimination of CO 2
 Bronchi / Bronchioles
 Cartilage structures
give way to smooth
muscle

 May divide up to 25
times before reaching
terminal bronchioles

http//medicalpicturesinfo.com/bronchial-tree/
 Alveoli
 Expand and contract with breathing
 Contact with pulmonary capillary beds for gas
exchange
 Inside surface coated with surfactant
 Prevents aveoli from sticking together
 Keeps alveoli open
 Atelectasis
 Mechanics of Respiration

 http://www.teachpe.com/anatomy/respiratory_system.php
 Functional Residual Capacity
 Lung volume at end of
normal exhalation
 Muscles of
respiration are
completely
relaxed

 http://www.lakesidepress.com/pulmonary/htm
 Gas Exchange

 http://www.uic.edu/classes/bios/bios100/lectures/circ.htm
 Oxygenation
 Process of getting oxygen to end organs and
tissues
 Inhaled through lungs
 Picked up from alveoli on RBCs
 Off-loaded in exchange for CO2

 Measured by pulse oximetry (SpO2)

 Ventilation
 Process to eliminate carbon dioxide (waste
product of energy production)
 Carried back through venous blood
 Eliminated through exhalation

 Measured by capnography
 Capnography
 The capnogram wave form begins before exhalation and ends
with inspiration. Exhalation comes before inhalation

 http://www.lusotech.com.br/catalogo/continuous-waveform-capnography
 Capnography Waveform

 http://medicscribe.com/:ffeb_network_search_context=blog/amp;s=pain/management
Respiratory
Disorders
 Respiratory Disorders

A combination of many disease processes

responsible for emergencies related to
ventilation, diffusion and perfusion.
 Respiratory Distress
 Subjective indication of some degree of
difficulty breathing
 Causes
 Upper or lower airway obstruction
 Inadequate ventilation
 Impaired respiratory muscle function
 Impaired nervous system
 Trauma
 Bronchitis, pneumonia, cancer
Respiratory Failure
 Clinical state of inadequate oxygenation, ventilation or
both.
 Often end-stage of respiratory distress
 Signs:
 Tachypnea (early)
 Bradypnea or apnea (late)
 Increased, decreased, or no respiratory effort
 Tachycardia (early)
 Bradycardia (late)
 Cyanosis
 Altered Mental Status
 Mechanism of Heart Failure
 Frequently a chronic, yet manageable
condition
 Left ventricle fails to work as effective pump
 Blood volume backs up into pulmonary
circulation
 Most often caused by:
 Volume overload
 Pressure overload
 Loss of myocardial tissue
 Impaired contractility
 Pulmonary Edema
 Cardiac and respiratory system impairment
 Acute and critical emergency
 Filling of lungs with fluid
 Washes away surfactant
 Creates pink froth in sputum
 Prevents alveoli from expanding
 Significantly reduces or eliminates ability for gas
exchange to occur
 Asthma
 Reactive airway disorder
 Exacerbation precipitated by extrinsic or
intrinsic factors
 Characterized by reversible bronchial smooth
muscle contraction, increased mucus
production and inflammatory airway changes
 Persistent signs and symptoms can indicate a
tenfold increase in the work of breathing
 Asthma
 Evolution of asthma attack
 Mucus thickens and
accumulates plugging
airways
 Mucosal edema
develops
 Muscle spasms constrict
small airways
 Breathing becomes
labored
 Exhalation becomes
difficult
http://asthma-ppt.com/asthma-pictures.html
 Caution
Asthma Anaphylaxis
Smoke, dander, dust, Nuts, shellfish, milk, eggs, soy,
Causes pollen, cold air, mold, wheat, insect stings,
cleaning products, medications, latex
perfume, exercise

Wheezing Face - itchiness, redness,

Symptoms swelling of face & tongue
Coughing
Shortness of breath Airway – trouble breathing,
Difficulty breathing swallowing or speaking
Stomach – abdominal pain,
Chest tightness
vomiting, diarrhea
Total hives, rash, itchiness,
swelling, weakness, pallor,
sense of doom, loss of
consciousness
 Chronic Obstructive
Pulmonary Disease
 Obstructive lung disease
 Triad of distinct diseases that often coexist
 Asthma
 Chronic bronchitis
 Emphysema

 Traditionally refers to patients with

combination of chronic bronchitis and
emphysema
 Chronic Bronchitis
 Bronchi become filled with excessive mucus
 Alveoli are not affected
 Diffusion of gas remains relatively normal
 Patients develop low oxygen pressures (PO2)
and hypoventilation
 Hypoventilation leads to high levels of CO2
and low levels of O2
 Emphysema
 Results from
pathological changes in
the lung
 Permanent abnormal
enlargement of air
spaces beyond
terminal bronchioles
 Collapse of the
bronchioles
 Destruction of the
alveoli

 http://health.allrefer.com/health/chronic-obstructive-
pulmonary-disease-emphysema.html
 Emphysema
 Patients have some
resistance to airflow,
primarily on exhalation
 Hyper-expansion
caused by air trapped
in the alveoli

 Breathing becomes an
active process

 Sanders, M.J. (2005) Paramedic Textbook (3rd ed.) St.

Louis: Mosby-Elsevier
 Emphysema
 Bleb formation

 Risk of pneumothorax
 Interior airway pressure

 CO2 Retention
 Potential worsening with CPAP
Continuous
Positive
Airway
Pressure
The use of CPAP prehospitally
reduces the need for intubation
by 30% and reduces mortality
by 20%
 Annals of Emergency Medicine, September 2008
CPAP
 Non-invasive ventilation

 Continuous O2
delivered at a set
positive pressure
throughout the
respiratory cycle

 www.ems1.com/cpap-for-ems
 Positive Pressure
 PUSHES air into the chest
 Overcomes airway resistance

 Bag valve mask

 Demand valve
 Intubation / mechanical ventilation
 CPAP
 Effects of CPAP
 Increases functional residual capacity

 Increases alveolar surface area available for

gas exchange

 Increases oxygen diffusion across alveolar

membranes

 Reduced work of breathing

 How CPAP Works
 Maintains constant level of airway pressure

 Keeps alveoli open (asthma, COPD)

 Moves fluid into vasculature (pulmonary edema)

 Improves gas exchange

 Buys time for medications to work

 Indications
 Severe Respiratory Distress / Respiratory
Failure
 Accessory muscle use?
 Persistent hypoxia despite appropriate /
aggressive oxygen therapy?
 Marked increased work of breathing?
 Inability to speak full sentences?

 Differentiate Pulmonary Edema versus other

Respiratory Disorder
 Contraindications
 Respiratory rate < 10 breaths / minute
 Systolic blood pressure < 100 mmHg
 Confusion
 Inability to understand directions and
cooperate with application of CPAP
 History of pneumothorax
 History of recent tracheo-bronchial surgery
 Active nausea or vomiting
 Despite antiemetic therapy by paramedics
 Limitations
 CPAP is not a mechanical ventilator

 Tight mask seal can create claustrophobic

response
 Consider allowing patient to self-seal (hold
own mask) until initial benefits recognized

 CPAP is powered by on-board oxygen supply

 Oxygen Utilization

Oxygen Demand
 Summary

Pre-hospital studies have proven the

effectiveness of CPAP in treating patients
with severe respiratory distress, regardless of
disease process.
 ANY
QUESTIONS
 Special Thanks
To:

Peter Canning for time and effort in initial

development of program
David Bailey for contributions of supplemental
information to enhance presentation
Richard Sanders for development of glossary of
terms
Nancy Brunet for final project coordination
Placeholder
 Add specific manufacturer product
information and local concerns
Practical
Skills
Session