# Is CPAP the Standard of Care?



## MMiz (Feb 1, 2009)

Is CPAP the Standard of Care?

Paramedics in Halifax, Canada were trained in the use of continuous positive airway pressure (CPAP) ventilation for patients in respiratory distress. They were skilled in drug-facilitated (midazolam) intubation and had a success rate of 96% for cardiac arrest and 90% for non-cardiac arrest intubations.

Read more!

Is there any reason why all services aren't using CPAP?


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## firecoins (Feb 1, 2009)

Yes. CPAP should be the standard of care.


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## bstone (Feb 1, 2009)

They just added CPAP for Intermediates in NH. I trained on it just last week for 4 hours.


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## VentMedic (Feb 1, 2009)

Standard of Care for who or/and what?

Read the full article.

http://www.annemergmed.com/article/PIIS0196064408000322/fulltext

He also made a statement about another study but did not provide a reference for it.



> This was unlike the *Hubble study*, where the medics were incorrect by confusing congestive heart failure (CHF) with chronic obstructive pulmonary disorder (COPD) half the time. Regardless of their misdiagnosis the CPAP showed improved morbidity and decreased mortality.


 
This is one of the many reasons why JEMS is not always the best read. Look at the original article and see for yourself if you agree it was a quality study with a large enough sample size. Read what the author states as limitations to the study. 

Also, NOT all prehospital machines are equal and may not produce the same results and some can increase work of breathing leading to failure quicker. 

The machine used in this study was the portable flow generator, Whisperflow by Respironics at 10 cm H2O. 
Not everyone in the field will have access to a flow generator like this.

Due to the gas consumption of these machines, chances are transport time is not long. In the ED the patient will be placed on machines capable of more flow, increased sensitivity and bilevel ventilation capability to decrease work of breathing.

The contributing authors to JEMS may over simplify an article as well as putting their own bias into their review by hitting the highlights of whatever point they are trying to make and skipping over other issues mentioned that might not support their own PERSONAL statement.


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## Ridryder911 (Feb 1, 2009)

Hence, why all Paramedics should be required to take a formal class on research and advanced statistics. Most are idiots when reading and interpreting studies. 

We have allowed Basics to iniatiate CPAP on CHF patients in my state. 

R/r911


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## bstone (Feb 1, 2009)

Ridryder911 said:


> Hence, why all Paramedics should be required to take a formal class on research and advanced statistics. Most are idiots when reading and interpreting studies.
> 
> We have allowed Basics to iniatiate CPAP on CHF patients in my state.
> 
> R/r911




While in class last week I quickly realized why CPAP is good for CHF. However what I was not taught was how to appropriately identify CHF. I was thinking about this yesterday and I realized that I can't. 

So, how does one identify CHF and not mistake it for COPD or other obstructive airway disorders? Or does it not matter- that we can do CPAP and not worry?


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## Hastings (Feb 1, 2009)

Standard for CHF, VERY selective for COPD.

And to answer the above question, fluid in the lungs.


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## bstone (Feb 1, 2009)

Hastings said:


> Standard for CHF, VERY selective for COPD.
> 
> And to answer the above question, fluid in the lungs.



What is the prehospital assessment for fluid in the lungs, other than ascultation?


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## Hastings (Feb 1, 2009)

bstone said:


> What is the prehospital assessment for fluid in the lungs, other than ascultation?



Well, look for peripheral edema. Other than that, just listen. It's hard to miss in CHF emergencies.

I mean, that's just the EMT-I answer, but for your purposes, if there is fluid in the lungs with a history of CHF...(and even better, if you can rule out pneumonia and the such)...CPAP-IV-Nitro-Lasix-Morphine...or whatever Intermediates can do.

Every time I've used a CPAP on a bad CHF, they've gone from telling me they were going to die to smiling as we enter the ER doors. So personal experience encourages the use.


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## bstone (Feb 1, 2009)

Hastings said:


> Well, look for peripheral edema. Other than that, just listen. It's hard to miss in CHF emergencies.
> 
> I mean, that's just the EMT-I answer, but for your purposes, if there is fluid in the lungs with a history of CHF, CPAP, IV, Nitro-Lasix-Morphine...or hwatever Intermediates can do.
> 
> Every time I've used a CPAP on a bad CHF, they've gone from telling me they were going to die to smiling as we enter the ER doors. So personal experience encourages the use.



So the primary indication (other than gurgling sound in lungs) is past dx of CHF? Based on that, treat with CPAP?


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## Hastings (Feb 1, 2009)

bstone said:


> So the primary indication (other than gurgling sound in lungs) is past dx of CHF? Based on that, treat with CPAP?



...Just listen to lung sounds. I don't feel comfortable telling an Intermediate that says they don't know how to recognize CHF to treat all patients with fluid in their lungs with the CPAP, but I'm just saying that it's a BIG indicator.

Severe difficulty breathing, history of CHF, fluid in the lungs, low SAT, and edema are a good start.


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## bstone (Feb 1, 2009)

Should one see pitting edema in CHF patients?


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## Hastings (Feb 1, 2009)

bstone said:


> Should one see pitting edema in CHF patients?



It's very possible.


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## bstone (Feb 1, 2009)

Hastings said:


> It's very possible.



In your experience how often does pitting edema occur in PTs with peripheral edema and CHF?


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## Hastings (Feb 1, 2009)

bstone said:


> In your experience how often does pitting edema occur in PTs with peripheral edema and CHF?



If my CHF patients have had peripheral edema, it has been pitting 100% of the time.

What I meant is that there have been certain times when a CHF patient has not had significant swelling in the periphery.


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## bstone (Feb 1, 2009)

Hastings said:


> If my CHF patients have had peripheral edema, it has been pitting 100% of the time.
> 
> What I meant is that there have been certain times when a CHF patient has not had significant swelling in the periphery.



Good to know. Peripheral edema and pitting edema are bedfellows, but they aren't always present in the case of CHF.


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## Ridryder911 (Feb 1, 2009)

bstone said:


> What is the prehospital assessment for fluid in the lungs, other than ascultation?


http://www.emtlife.com/showthread.php?t=3615

Here is a post I wrote a while back on another forum, but thought it would might be helpful to some new or review for others...on CHF 

I have found most EMT's do not understand CHF, I would like to try to simplify & educate some misconceptions of CHF. 
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

What is CHF ? CHF stands for congestive heart failure. CHF is not a kind of heart disease. Heart disease is called cardiomyopathy and it's cardiomyopathy that causes heart failure. Heart failure is the set of symptoms that hit you when your heart can't pump enough blood to meet your body's needs. It's called congestive because fluid settles in your lungs, "congesting" the patients airway.. 

The patients may have a weak heart (pump problems), & probably an enlarged heart (cardiomegally-from working too hard.. you know muscles build up from resistance). They may have "episodes" of heart failure, meaning sometimes they have the symptoms and sometimes they don't. Or they may have symptoms all the time. However patientÂ¡Â¦s are only in CHF when they have symptoms. (symptomatic). The symptoms include shortness of breath, fatigue, lightheadedness, swelling, insomnia, & may complain of increasing shortness of breath at nighttime..(nocturnal dyspnea). 

If they don't usually have symptoms, they are called "well compensated." This means meds and life style changes are compensating for the weak heart function. If they are in CHF, meaning that you have all or some of those symptoms, they are called "decompensated." With good treatment your CHF (symptoms) may go away, but that doesn't mean they are cured. They should be kept on certain drugs even if they have no symptoms . 

What is happening to the heart ? 
Your lungs take the oxygen you breathe in and put it into your blood. Your heart pumps that oxygen-rich blood out of your lungs into the rest of your body. Your other organs and tissues get a good drink of oxygen-rich blood and then it goes back through your lungs, picking up oxygen again. The heart pumps it out again and again and again - we can only hope. 

A weakened heart can't pump hard enough to keep up with this cycle. It receives more blood from the lungs than it can pump out into the body with each heart beat. The blood it can't handle backs up, spilling over into the lungs and other tissues. Cells get waterlogged. This causes swelling called edema. 

This swelling often happens in the lower back (sacral), ankles (pedal) and legs first (tibial). That's because gravity pulls the backed-up, "loose" fluid straight down. The fluid also backs up into your lungs, which makes it hard to breathe. When you're lying down, gravity isn't pulling the fluid out of your lungs down into your feet, so it is even harder to breathe. Your heart can fail in two basic ways: 

Systolic dysfunction is when the heart can't pump out enough blood. Most CHFers have this problem 
Diastolic dysfunction is when enough blood cannot get into the heart because the heart muscle refuses to properly relax. Because the heart doesn't relax, there isn't enough room inside it for all the blood. With diastolic dysfunction, the heart may be normal size and they may have a normal ejection fraction 

Do they really have heart failure? 
The heart does not just stop if you go into heart failure. Usually patients get heart failure over a period of time - maybe even years - before it is diagnosed. Heart failure causes shortness of breath, swelling of legs, feet and maybe their stomach (ascites). They can get a feeling of fullness in your stomach that makes it hard to breathe. Sleeping can be difficult. Wheezing & fine mixture of fluid & air produce lung sounds called crackles or us old timer call it rales. Extreme fatigue is common. 

Heart failure is often misdiagnosed as respiratory infection, bronchitis, asthma or gallstones. Certain tests can identify heart failure in different ways. A chest x-ray can show if the heart is enlarged. An echocardiogram can measure how well the heart is pumping, checking blood flow pattern & working of the valves. (Ejection fraction (EJ %) = blood flow amount ). A new 20-minute blood test called the BNP or HBNP test can confirm a CHF diagnosis, you may see this in the ER & definitely in ICU/CCU arenaÂ¡K usually > 100 represents CHF & may show up before signs & symptoms appear 
. Some common causes of congestive heart failure are there are several: 
â€žX Coronary artery disease 
â€žX High blood pressure, usually over a period of years 
â€žX Heart valve disease 
â€žX Infections, such as from viruses (including Coxsackie and HIV), bacteria or parasites 
â€žX Diseases of the pericardium - a fluid-filled sac around the heart 
â€žX Myocarditis - inflammation of the heart walls 
â€žX Drugs - especially chemotherapy - such as doxorubicin (Adriamycin), cyclophosphamide (Cytoxan) or cocaine 
â€žX Excessive alcohol drinking 
â€žX Connective tissue disease 
â€žX Tachycardia - a too-fast heart rhythm, usually over a period of years 
â€žX Obstructive cardiomyopathy, also called restrictive cardiomyopathy 
â€žX Neuromuscular diseases such as muscular dystrophy or Friedreich's ataxia 
â€žX Metabolic disorders, such as Pompe's disease or McArdle's disease 
â€žX Nutritional disorders, such as beriberi or kwashiorkor 
â€žX Radiation 
â€žX Hypertrophic cardiomyopathy (HCM or IHSS) 
â€žX Peripartum cardiomyopathy (PPCM), caused by strain on the heart during pregnancy 
â€žX Dilated idiopathic cardiomyopathy - heart enlargement and heart weakness of unknown cause 
â€žX Severe anemia 
â€žX Hypothyroidism (underactive thyroid) or hyperthyroidism (overactive thyroid) 

WOW didn't know there were so many huh ? 

Can they cure CHF ? 
Cardiomyopathy may get cured, but the heart usually sustains some permanent damage pior to the underlying problem is fixed. This is one reason it's a question with no answer. It depends completely on the individual circumstances. 
Some meds you might or may see: 

CE Inhibitors 
Vasotec enalapril 
Altace ramipril 
Monopril fosinopril 
Capoten captopril 
Prinivil/Zestril lisinopril 
Accupril quinopril 
Lotensin benazepril 
Aceon perindopril erbumine 
Mavik trandolapril 
Angiotensin-converting enzyme (ACE) inhibitors are the first-line therapy for CHF. ACE inhibitors prevent worsening of heart function and lighten the heart's work load. There can be large price differences from drug to drug. Watch for lightheadedness and persistent, dry cough. 

ARBs 
Cozaar (losartan) 
Avapro irbesartan 
Atacand candesartan cilexetil 
Diovan valsartan 
ARBs are ACE Receptor Blockers. They are also called ACE 2 antagonists. ARBs such as losartan may give many of the same benefits as ACE inhibitors without side effects such as cough. However, ACE inhibitors are still more important in CHF treatment than ARBs because they have been thoroughly proven to make them feel better and live longer. 

Part 2 to follow...


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## Ridryder911 (Feb 1, 2009)

http://www.emtlife.com/showthread.php?p=38752
In continuation of part 1 article

Treatment include :
Diuretics make them pee remove fluid 
Demadex torsemide 
Lasix furosemide 
Bumex bumetanide 
Indapamine indapamide 

Hydrachlorothiazide Diuretics (HCL) wring fluid out of your system the old fashioned way: they make you pee. The less fluid in your system, the less blood your heart has to pump, the less congestion in your lungs, and the easier you breathe. There are 2 types of diuretics: loop and thiazide. Loop diuretics are more powerful. One mg of Bumex = 10mg of Demadex = 40mg of Lasix. 
Loop diuretics cause potassium, magnesium, thiamine, and calcium loss but since ACE inhibitors slow potassium loss, they may offset each other. A very small dose (2.5 mg) of Zaroxolyn taken 30 minutes before your Lasix can really turbocharge the draining effect. Be sure they take Lasix 1 or 2 hours before or after eating (not with food) - with Demadex it doesn't matter. 
Please note that Demadex may be better for CHFers than Lasix. .. Magnesium, potassium, calcium, and vitamin B1 supplements are recommended. Watch for gout and avoid licorice! 

Cardiac 
Digoxin 
Lanoxin 
digoxin Digoxin/Lanoxin is a "cardiac glycoside." Such therapies have been used for weak hearts for centuries. Digoxin is still useful, especially in severe CHF. It helps the heart beat stronger and reduces CHF symptoms. Watch for confusion, nausea or visual disturbances. Also watch for swollen breasts (man or woman) and breast tenderness with long-term use 
Beta-blockers 
Beta-blockers 
carvedilol 
Zebeta 
bisoprolol 
Toprol XL 
metoprolol Beta-blockers prevent the body from telling the damaged heart to speed way up. An accelerated heart rate would wear the heart out way too fast. Coreg is the most widely used but others may work as well - or not. Beta-blockers make us live longer and many CHFers - but not all - feel better taking them. Coreg is an alpha and beta-blocker with several other actions as well. Watch for hypotension, bradcardia, lightheadednesss, weight gain, or depression. Should be taken food! If they are diabetic and take a beta-blocker, check their blood sugars very closely! 

Coumadin 
Coumadin 
warfarin Although commonly used in CHFers to prevent blood clots (and thus strokes), there is little evidence that this is necessary unless they have a-fib (atrial fibrillation)( irregular heart firing of the top part of the heart). If they have a-fib, they will need a blood thinner. Coumadin is questionable for CHFers in normal (sinus) rhythm, unless they have a history of clots or stroke. Watch for a tendency to bleed easily. Bruising is common. They will need to have your blood tested regularly if on Coumadin. PT/PTT/INR to check blood thickness, and clotting time 

Aspirin 
aspirin: Once commonly used in CHFers who were not taking Coumadin, there is no evidence that all CHFers should take aspirin every day. 

Aldosterone-blockers 
Aldactone 
spironolactone 
Inspra 
eplerenone Long approved as a diuretic, the RALES trial showed a new use for this old drug. Taken at low doses - 25mg daily - it does not act as a diuretic but it does makethem less likely to die. It affects potassium, like most diuretics, so a blood test should be done when the drug is started, at the very least. Watch for growing breasts - 1 in 10 men will suffer this or impotence. The swollen breasts in men will not disappear if you stop taking the drug. 
A new drug called eplerenone may give the same benefits without all the side effects 

Vasodilators 
Apresoline 
hydralazine 
Isordil/Sorbitrate 
isosorbide dinitrate 
Many brand names of 
nitroglycerin 
Imdur 
isosorbide mononitrate 
Vasodilators expand the blood vessels, lowering the resistance against which the heart must pump. This is called reducing afterload. These can be powerful drugs, so use with care. Watch for headaches and dizziness. Alpha blockers are vasodilators and expand blood vessels, and Coreg has this effect to some extent. 

In the pre-hospital phase : Morphine, Nitrates (nitroglycerin) Oxygen, Lasix or some other dieuretics
Morphine dilates veins - called reducing preload - and decreases anxiety 
Nitroglycerin also dilates coronary arteries as well & dilates vessels 

IV Drugs 
Primacor IV 
milrinone 
Inocor IV 
amrinone lactate 
dobutamine 
dopamine 
Natrecor 
nesiritide Usually given intravenously, inotropes and certain other IV drugs make the heart pump more strongly (inoropic effect). They are usually used only in severe CHF and are fairly short acting. Since they speed up the wearing out of the heart (myocardium), they are not used unless really necessary. They do really help quality of life in severe or end-stage heart failure, though. They are used in hospitals or at home, with therapy started by a visiting nurse (home health) Natrecor is a new drug that has many of an inotrope's benefits without many of the side effects 

Statins 
Zocor simvastatin 
Mevacor lovastatin 
Pravachol pravastatin 
Lescol fluvastatin 
Lipitor Atorvastatin For those CHFers who have CAD, cholesterol control is crucial. Because less physical activity raises LDL, most CHFers are put on drugs to maintain healthier cholesterol levels. Watch for constipation, stomach upset, or muscle cramps. Many cholesterol lowering drugs lower the CoQ10 level. The price of different cholesterol lowering drugs may differ & costs drastically. If they suffer muscle weakness or soreness a lot after starting a statin drug, they should see their doctor immediately since a rare side effect causing this can be dangerous. Actually ruptruring muscles.

Understanding CHF is the key factor for the EMT or Paramedic..
R/r 911


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## marineman (Feb 1, 2009)

Well written and informative rid. I have a few questions from it though, first is towards the end you mention a last line possibility being dopamine. We will probably never hit that point in the field but hanging dopamine for CHF you go with a lower dose than our ACLS 2-10mcg/kg/min right? Also at the lower dose does that prevent some of the vasoconstricting effects of dopamine? It seems like hanging a vasoconstrictor would be counter productive unless at that dose it's positive inotropic effect greatly outweighs the vasoconstriction.

Last question why avoid licorice?


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## Aidey (Feb 1, 2009)

Just a stab in the dark, but licorice is known to raise the BP, which is my guess why it says to avoid it.


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## marineman (Feb 1, 2009)

Aidey said:


> licorice is known to raise the BP



cool, that was not known by me but now it is. I'm going to start hanging bags of twizzlers instead of dopamine.


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## Aidey (Feb 1, 2009)

lol, I think it's only the real licorice, not twizzlers, which are arguably not real licorice (at least it's not according to my best friend).


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## VentMedic (Feb 1, 2009)

Aidey said:


> lol, I think it's only the real licorice, not twizzlers, which are arguably not real licorice (at least it's not according to my best friend).


 
The black Twizzlers can also have cause sodium retention and potassium loss if consumed in *large* quantities.


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## Aidey (Feb 1, 2009)

Oooo, I forgot they made black ones. I HATE licorice with a passion.


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## Ridryder911 (Feb 2, 2009)

marineman said:


> Well written and informative rid. I have a few questions from it though, first is towards the end you mention a last line possibility being dopamine. We will probably never hit that point in the field but hanging dopamine for CHF you go with a lower dose than our ACLS 2-10mcg/kg/min right? Also at the lower dose does that prevent some of the vasoconstricting effects of dopamine? It seems like hanging a vasoconstrictor would be counter productive unless at that dose it's positive inotropic effect greatly outweighs the vasoconstriction.
> 
> Last question why avoid licorice?



Actually the side effect of Dopamine is vasoconstriction. Dopamine has three major effects all dependent upon the dosage. Low doses at one time was considered to actually lower bood pressure and increase venous return. In reality it does some, not as much as we thought. Middle range dosages increases messentric dilatation and can increase renal perfusion somewhat. It is at the high range (Alpha) that vasoconstriction occurs, and one will also witness a decrease in urine and increasing risk to the renal system. 


Licorice-licorice active ingredient is glycyrrhizin and that itself can cause 'pseudoaldosteronism' or 'mineralocorticoid syndrome' due to the effects on the adrenal glands. Symptoms include headache, lethargy, muscular weakness or aches, high blood pressure, sodium and water retention, increased potassium loss, and sometimes even cardiac arrest. Symptoms can manifest within one week if the daily ingestion of licorice is over 100 g. Deglycyrrhizinated extracts are virtually free of adverse mineralocorticoid side effects. 
Adverse reactions to ingesting licorice products are more common in individuals who have hypertension, kidney or heart disorders, hypokalemia, liver disease, and hypertonia. 
Licorice may affect the way certain drugs work, especially diuretics and anti-hypertensive drugs


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## Outbac1 (Feb 3, 2009)

This was a study done only in the Metro/Halifax area of the province.  Despite the outcome from the study there are still no CPAP devices on any ambulances in the province. When the study was done the units came off the trucks. 

  There are a lot of medics who would like to have CPAP as a tool to use.

  The wheels of politics and medicine can move slowly everywhere.


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