CPAP in the Spiral

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CPAP in the Spiral

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In essence, I think the evidence shows that CPAP is one of the most useful tools in the pre-hospital armament in the treatment of respiratory illness. The pitfalls as I see them are using them in the wrong patient (one who needs another form of therapy first) and not selling CPAP well to the patient.  Five minutes of really good coaching is worth the next 45 minutes of fighting a hypoxic patient on a call, and even worse, intubating them when a few kind words and CPAP would have done the work.  Ventilator Acquired Pneumonia in intubated patients is very costly to the health care system and results in increased patient mortality and morbidity.

 

The following is the position statement of the National Association of EMS physicians http://www.naemsp.org/Documents/Position%20Papers/POSITION%20NIPPV-Resource%20Doc-2011.pdf

 

The Canadian Pre-hosital Evidence Based Practices group (paramedicresearch.com) has extensively reviewed evidence around the use of CPAP and it has one of the strongest evidence for pre-hospital intervention. See this page for their levels of evidence https://emspep.cdha.nshealth.ca/MethodLOEChart.aspx.  and check out the Methods tab on the left side of the main page.

 

PEBP reviewed 19 studies which showed positive benefit with the use of CPAP in CHF with Pulmonary Edema and 9 neutral studies. See the section entitled NIPPV

https://emspep.cdha.nshealth.ca/LOE.aspx?VProtStr=Pulmonary%20Edema%20(CHF)&VProtID=202

 

In the case of COPD, there were 5 positive studies and 1 neutral https://emspep.cdha.nshealth.ca/LOE.aspx?VProtStr=COPD&VProtID=201

 

In the case of Asthma there were 3 studies they were positive and 1 neutral

https://emspep.cdha.nshealth.ca/LOE.aspx?VProtStr=Asthma&VProtID=200

 

Finally, in the case of SOB NYD, there were two positive studies https://emspep.cdha.nshealth.ca/LOE.aspx?VProtStr=Respiratory%20Distress%20NYD&VProtID=204

 

As to the variability in FiO2 in BVM as mentioned in the presentation, see http://monashanaesthesia.org/bvm/

 

You can find the article by Levitan and Weingart on the NODESAT technique at http://www.annemergmed.com/article/S0196-0644%2811%2901667-2/pdf

 

Also see  on the notion of poor man’s CPAP and BiPAP on this great video at https://www.youtube.com/watch?v=6AXyW7zrde4

 

As usual, if you have question, feel free to comment below.

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Gene Benoit

Gene Benoit, CCP is a Critical Care Flight Paramedic and Clinical Educator from Vancouver, British Columbia.
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By | 2016-10-23T11:17:29+00:00 November 15th, 2014|3 Comments

3 Comments

  1. Gene Benoit November 23, 2014 at 11:49 pm

    A fellow CCP and all around good guy named Robert Milton was speaking to me about the physiology of CPAP and although he liked the presentation he said learners may benefit a little more from the physiology. On initial read, this may be valuable to the watcher re physiology:
    http://web.squ.edu.om/med-Lib/MED_CD/E_CDs/anesthesia/site/content/v05/050035r00.htm

  2. Graeme Parke August 5, 2015 at 11:30 pm

    Hi Gene,
    My partner and I were chatting about CPAP today and came up with a question regarding the T-piece. I figured this was the best forum to bring it up…

    When nebulizing meds through a CPAP mask with a T-piece and you’re only using one tank, do you need to adjust the flow rate to accommodate for the extra resistance from more tubing? I’ve only ever used two O2 tanks to do this, but the Tx guidelines show a diagram of how to nebulize meds and run CPAP while only using one tank. Is one method more effective than the other? If you need to adjust the flow rate, what would the new settings be?

    Thanks,
    Graeme

  3. Gene Benoit August 6, 2015 at 12:06 am

    Hi Graeme,
    Another great question. See the pictures below. There is a green nipple at the bottom of the new BLS Systems CPAP device. You can run a line directly from this green nipple piece to the nebulizer. Here is the important thing – you need to increase the oxygen flow by 7 litres per minute from what the chart or graph tells you. So, if you use the chart below and you set a CPAP of 5 cmH2O, you will need to set the oxygen flow to 12 lpm (5 lpm as per the chart + 7 lpm as per the increase when using the nebulizer via the green nipple area). Let me know if that makes sense.

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