# CPAP vs BiPAP



## NightHealer865 (Sep 18, 2018)

For your pulmonary edema/chf patients, which do you prefer? Our vents will do both and we have protocols for both, but this is the first time I've ever had a vent and able to do BiPAP. Why do you prefer one over the other?


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## NPO (Sep 18, 2018)

I always do BiPAP for both pulmonary edema and COPD. I have very good success and it's always been well tolerated. Much more than the ol' Pulmodyne CPAP.


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## Peak (Sep 18, 2018)

CPAP is essentially non-invasive PSV - a weaning tool or for very minimal support, BiPAP allows a greater inspiratory pressure without the constant increase in PEEP and many BiPAPs allow setting similar to AC where you can set mandatory ventilation rates and volumes.

For patients requiring acute respiratory support for whom non-invasive airway management in appropriate we always start with BiPAP in lieu of CPAP. We only use CPAP for chronic patients who are already on CPAP do not have an increased need for support over baseline. I get those plastic disposable CPAPs that 911 ALS carries over nothing, but if you have the option why choose the support with less control? We leave weaning to the ICU/PICU/NICU receiving the patient.


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## NightHealer865 (Sep 18, 2018)

Peak said:


> CPAP is essentially non-invasive PSV - a weaning tool or for very minimal support, BiPAP allows a greater inspiratory pressure without the constant increase in PEEP and many BiPAPs allow setting similar to AC where you can set mandatory ventilation rates and volumes.
> 
> For patients requiring acute respiratory support for whom non-invasive airway management in appropriate we always start with BiPAP in lieu of CPAP. We only use CPAP for chronic patients who are already on CPAP do not have an increased need for support over baseline. I get those plastic disposable CPAPs that 911 ALS carries over nothing, but if you have the option why choose the support with less control? We leave weaning to the ICU/PICU/NICU receiving the patient.


That is kinda what I figured, but until recently all I had was the disposable CPAP that every private EMS service carries. Now that I have a ventilator with the BiPAP settings I think I'll try it on my next CHF patient.


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## Brandon O (Sep 18, 2018)

Most folks who are working to breath probably benefit from a little extra inspiratory support. Just bear their disease process in mind to help remind you whether they need mostly IPAP or mostly EPAP.


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## DesertMedic66 (Sep 18, 2018)

I’ve only been able to use CPAP due to being on a ground ambulance with no vent. Now I have full access to a vent. Our preferred mode for CHF/pulmonary edema is CPAP.


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## ThadeusJ (Sep 19, 2018)

When given the choice, most healthcare professionals would prefer Bilevel (BiPAP is a brand name of Respironics) over CPAP because you are able to control more parameters.  That being said, I don't believe there is a scientific based consensus on which provides better patient outcomes.  Also, Bilevel (at the moment) is only available on vents or non-disposable devices and require more training to use.  They will also more expensive, require servicing, a source of power and consume more oxygen resources.  

It all depends on where you are, what training you have and what equipment is available for your service.


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## VFlutter (Sep 19, 2018)

Like mentioned If they are at the point of respiratory failure from pulmonary edema then they will likely appreciate the added IPAP with Bilevel.


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## DrParasite (Sep 20, 2018)

We typically only use for severe Asthma or CHF....  which is better?  is that a preference, or is there a scientific study backing your rational?

And does anyone carry both CPAP and BiPAP on their truck?  I have only seen one system, never 2.


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## NightHealer865 (Sep 20, 2018)

DrParasite said:


> We typically only use for severe Asthma or CHF....  which is better?  is that a preference, or is there a scientific study backing your rational?
> 
> And does anyone carry both CPAP and BiPAP on their truck?  I have only seen one system, never 2.



Our Vents allow both, and we have protocols for both.


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## StCEMT (Sep 20, 2018)

I would prefer to have at least the option to use BiPAP, but all we have is CPAP. However, our CPAP is very user friendly, so that is nice.


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## NPO (Sep 20, 2018)

DrParasite said:


> We typically only use for severe Asthma or CHF....  which is better?  is that a preference, or is there a scientific study backing your rational?
> 
> And does anyone carry both CPAP and BiPAP on their truck?  I have only seen one system, never 2.


We carry both CPAP and BiPAP


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## Peak (Sep 20, 2018)

For any disease process in which the patient works to push air out I think that there is a huge benefit of BiPAP over CPAP, whether it be for COPD, Asthma, or patients who are just getting tired out from breathing. 

I have heard arguments that breath stacking patients benefit less from BiPAP because they let the pressure over-inflate them, I don't buy into this because you can adjust your IPAP and ramp to prevent them from doing this (and have yet to actually see a prehospital or ED patient do this, I've only seen it up in the units). These patients are often so close to complete failure anyway that they often need imminent intubation. 

I think that BiPAP is less adventitious over CPAP in patients where increasing PEEP is our primary goal, for example in CHF or other fluid overload states (for example the septic liver failure patient that we fill with fluids); however BiPAP isn't counter indicated and isn't really detrimental, just less adventitious. 

I would make sure that you have the T-connector for intermittent and continuous nebs, I know that there are some ways to rig it up with the peace pipe nebs but having the connector with a one way valve makes it so much easier to just start a treatment and leave the connector in place. 

Now to search out some literature...


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## Tigger (Sep 20, 2018)

DrParasite said:


> We typically only use for severe Asthma or CHF....  which is better?  is that a preference, or is there a scientific study backing your rational?
> 
> And does anyone carry both CPAP and BiPAP on their truck?  I have only seen one system, never 2.


When we start carrying a real vent we will likely have both CPAP and BiPAP onboard.


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## Peak (Sep 20, 2018)

Trials essentially show in adults that CPAP is better tolerated and has better patient comfort than BiPAP, however BiPAP had better outcomes in disease states other than CHF; in CHF there was no difference in outcome between CPAP and BiPAP.

https://www.uptodate.com/contents/n...&topicRef=3450&anchor=H16&source=see_link#H16
https://www.ncbi.nlm.nih.gov/pubmed?term=8294627
https://www.ncbi.nlm.nih.gov/pubmed?term=21136039
https://www.ncbi.nlm.nih.gov/pubmed?term=10713013

Peds has less literature on the manner and emphasis other adjuncts for various disease states, for example HHF and cough assist which aren't as relevant to EMS discussions. 

https://www.uptodate.com/contents/n...Title=1~150&usage_type=default&display_rank=1

Anecdotally we tend to start almost all of our PICU kids BiPAP, we tend to see much more use of CPAP in the NICU. Since of course BiPAP (or any giant mask gripping their face) is often poorly tolerated we often place these kids on precedex and have 1:1 monitoring.


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## RocketMedic (Sep 20, 2018)

NightHealer865 said:


> For your pulmonary edema/chf patients, which do you prefer? Our vents will do both and we have protocols for both, but this is the first time I've ever had a vent and able to do BiPAP. Why do you prefer one over the other?


Where's this at? I miss vents.


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## RocketMedic (Sep 20, 2018)

For my money, I prefer bilevel NIPPV for its versatility, but it can be difficult to get people used to the dual levels, especially when they're tachypneic and anxious. CPAP really shines in its ability to present a *consistent* pressure, and anecdotally, I find it much easier to tolerate, even the disposable ones. NIPPV through a vent, properly managed, burns a lot less O2 than a Pulmodyne or other oxygen-powered unit. 

I really, really like "ghetto bipap" too. BVM + PEEP valve and a repurposed CPAP mask or BVM facemask actually does a surprisingly OK job, especially with patients who are already so distressed as to be unable to tolerate CPAP. 

Short answer: give me a good vent, the autonomy to use it and let me pick what works best.


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## NightHealer865 (Sep 20, 2018)

RocketMedic said:


> Where's this at? I miss vents.



EMSA OKC believe it or not.


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## RocketMedic (Sep 20, 2018)

Ah! You should get a little fire truck lunch box, people will go insane.


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## truetiger (Nov 2, 2018)

If you have a vent that does both your going to want to almost always use the non-invasive positive pressure ventilation with pressure support...


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## NPO (Nov 2, 2018)

We carry a vent on all trucks that does CPAP and Bi-level pressure support (BIPAP). 

I agree, that BIPAP can be harder to tolerate, which is why I've asked my medical director (and he agrees) to add versed for anxiolysis for CPAP/BIPAP. I'll be introducing the topic to our clinical committee next week. We will also discuss ketamine since it has bronchodilator effects.


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## truetiger (Nov 2, 2018)

For its bronchodilator effect or to disassociate to BiPAP?


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## NPO (Nov 2, 2018)

truetiger said:


> For its bronchodilator effect or to disassociate to BiPAP?


Yes.

Not quite disassociate, but reduce anxiety. Low doses. 

I don't think a fully disassociated person on CPAP would be a good idea lol. We need more literature on this though, so if you have some send it my way.


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## truetiger (Nov 2, 2018)

If you want to reduce anxiety, just use a benzo. If you're to the point that a benzo isn't cutting it and you're still needing to get them on BiPAP (I would worry about getting actual BiPAP before ketamine) you're probably going to be tubing them. Ketamine -> BiPAP-> Tube. If it turns around and they don't need tube, great, if not, you're set up for DSI.


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## NPO (Nov 2, 2018)

truetiger said:


> If you want to reduce anxiety, just use a benzo. If you're to the point that a benzo isn't cutting it and you're still needing to get them on BiPAP (I would worry about getting actual BiPAP before ketamine) you're probably going to be tubing them. Ketamine -> BiPAP-> Tube. If it turns around and they don't need tube, great, if not, you're set up for DSI.


Not in addition to, but instead of versed. If the ketamine can calm them, and give a little bronchodilation while they're on CPAP or BIPAP, great. If it doesn't end up being enough, then you're already set up for DSI.

However, like I said, we need more literature on this. Currently, we will only be adding the versed for anxiolysis and to increase CPAP/BIPAP compliance, but would like to discuss ketamine for this process as well.


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## truetiger (Nov 2, 2018)

Give mag if you want to add some bronchodialtion. CPAP isn't going to cut it for COPD. You're going to need inspiratory support to get them over the hump. The pressure support is going to blow open the alveoli and the PEEP will keep them open. As far as the Ketamine goes, why are you hesitant to disassociate them?


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## TXmed (Nov 3, 2018)

@NPO given low doses of ketamine for anxiety isnt really the best thing to do. Giving ketamine to a cardiac patient with pulmonary edema really isnt the best thing to do. Ketamine has been shown to reduce LV function and increase PA pressure. I would just focus more on making the BiPap work and not get too cute with things.


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## Brandon O (Nov 3, 2018)

I would advise great caution with giving benzos to these patients. They need to breathe.


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## DrParasite (Nov 3, 2018)

Brandon O said:


> I would advise great caution with giving benzos to these patients. They need to breathe.


I would have thought that all patients needed to breathe.....


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## Brandon O (Nov 3, 2018)

DrParasite said:


> I would have thought that all patients needed to breathe.....



Yeah... but it's easy for you.


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## Carlos Danger (Nov 3, 2018)

Ketamine is not a great anxiolytic in small doses. IME, benzos work well for this purpose and most folks tolerate small doses just fine, but you will occasionally see someone’s respiratory drive take a hit with even small doses of a benzo, especially if they are tired to begin with. In general I would really try to avoid giving any kind of sedation to someone who is struggling to breath, but if there’s just no way they’ll tolerate the mask without it, a moderate dose (25-50mg) of ketamine might be your best bet.


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## Brandon O (Nov 3, 2018)

Remi said:


> Ketamine is not a great anxiolytic in small doses. IME, benzos work well for this purpose and most folks tolerate small doses just fine, but you will occasionally see someone’s respiratory drive take a hit with even small doses of a benzo, especially if they are tired to begin with. In general I would really try to avoid giving any kind of sedation to someone who is struggling to breath, but if there’s just no way they’ll tolerate the mask without it, a moderate dose (25-50mg) of ketamine might be your best bet.



I would be a bit wigged out about a borderline COPD patient wearing a mask having a bad ketamine reaction...


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## Peak (Nov 3, 2018)

I don't know of any services that carry it in the field but precedex works great.


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## Brandon O (Nov 3, 2018)

Peak said:


> I don't know of any services that carry it in the field but precedex works great.



Yes, good choice for this. Best used before they're freaking out too much, as it takes some time to build up. (Loading doses are out of fashion, but you CAN do it if their HR and BP are robust.)


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## E tank (Nov 3, 2018)

truetiger said:


> Give mag if you want to add some bronchodialtion.




I KNEW mag sulfate would make it in here some how...


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## Carlos Danger (Nov 3, 2018)

Brandon O said:


> I would be a bit wigged out about a borderline COPD patient wearing a mask having a bad ketamine reaction...


Well, like I said I would avoid any of this if at all possible. But I wouldn’t worry much about a bad trip anyway. Not only is it fairly unlikely in that dose range (especially if you stay closer to the lower end), but a tripping patient who is breathing well is much better than a lucid one who isn’t.

Edit: I use 25mg of ketamine (and sometimes two or three times that) for sedation for nerve blocks every day.


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## Brandon O (Nov 3, 2018)

Remi said:


> Well, like I said I would avoid any of this if at all possible. But I wouldn’t worry much about a bad trip anyway. Not only is it fairly unlikely in that dose range (especially if you stay closer to the lower end), but a tripping patient who is breathing well is much better than a lucid one who isn’t.



Right, but if the issue is anxiety, suddenly introducing a herd of cackling were-pandas to the room may not help...

In my world, a subdissociative (pain) dose of ketamine is .1-.3 mg/kg (or around 10-25 mg), and I have certainly had people complain of unpleasant dysphoria toward the upper end of that range, particularly when pushed. Full dissociation is closer to 1 mg/kg -- and I haven't found much use for in-between doses. Doesn't seem like partial dissociation would help much with anxiety.

Well -- that's not true. In reality, I've used doses around 50 mg for procedural-type sedation in the ICU setting -- in fact I've rarely gone much higher. But that's in shocky, ill patients, and I think it's acting like a much higher dose.


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## Peak (Nov 3, 2018)

Brandon O said:


> In my world, a subdissociative (pain) dose of ketamine is .1-.3 mg/kg (or around 10-25 mg), and I have certainly had people complain of unpleasant dysphoria toward the upper end of that range, particularly when pushed. Full dissociation is closer to 1 mg/kg -- and I haven't found much use for in-between doses. Doesn't seem like partial dissociation would help much with anxiety.
> 
> Well -- that's not true. In reality, I've used doses around 50 mg for procedural-type sedation in the ICU setting -- in fact I've rarely gone much higher. But that's in shocky, ill patients, and I think it's acting like a much higher dose.



I've certainly seen patients starting to experience significant alterations in sensorium even at only 0.2 mg/kg including hallucinations, alteration in the perception of time, complaints of "fractals"/narrowing perception of vision/objects "jumping" in their field of vision; which has resulted in significant anxiety. These seem to be especially prevalent when administered quickly, including infusions times as long as five minutes on IVPB or syringe pump. 

I actually cared for a patient who ended up with a stress/demand inducted STEMI when she had been given ketamine at 0.2 mcg/kg and shortly afterwards informed that she could not have narcotics due to being on a narcotic medication stewardship plan (and a complaint of exacerbation of chronic pain). 

I think that this is pretty patient specific because I've also given 0.5 mg/kg ketamine doses as a slow push (1-2 minutes) to patients with severe intractable pain not responsive to high dose IV narcotics who had good pain relief and minimal alteration in sensorium. This has been in adults and peds, and most of these patients were either opioid naive or with relatively little prior exposure including splenic infacts, multi-system trauma, ischemic bowel, compartment syndrome, and so on. 

We have used ketamine as a partial dissociate for conscious intubations, with other adjudicative medications such as a lido neb, with pretty good success. Every time we have used this method though it has been from patients with prior intubations/ICU management for whom the intubation itself was not as frightening as their disease process (to the patient anyway); typically on COPD, CHF, Asthma/RAD, and HAE patients. We've always intubated with the patient in a seated position and used either a glidescope or bronch so I doubt there is a lot of use in the field, let alone outside of the critical care setting. 

For patients with relatively poor tolerance but can be coached I think that precedex is a great drug, a small dose of ativan or valium might be helpful but can potentially cause worsening respiratory status. I would think most of the patients who would probably be able to tolerate/benefit ketamine could probably be coached for a period of time anyway; with the exclusion of asthma/RAD. In my experience patients who are in distress and truly fight the BiPAP (excluding pediatrics) typically get tubed shortly anyway.


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## Carlos Danger (Nov 3, 2018)

Brandon O said:


> Right, but if the issue is anxiety, suddenly introducing a herd of cackling were-pandas to the room may not help...



But if we’re talking about patients having a respiratory emergency and making a last ditch effort to avoid intubation - especially prehospital - I think the small risk of worsening anxiety is worth it.

It isn’t really even a _risk_, because if you give someone a small dose of ketamine and they start to get a little crazy, there’s an easy fix.....more ketamine.


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## NPO (Nov 3, 2018)

I know I lit the candle, and k live ketamine, but I'm not SOLD on the idea for it for this purpose. Not yet. Hopefully data will come out. It's just something we are going to throw around. I do already have approval for Versed from the medical director because he agrees with me that the benefit to successful CPAP/BIPAP is worth the risk because CPAP/BIPAP is so good at reducing intubation rates.


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## truetiger (Nov 3, 2018)

Having used ketamine a lot...and for this purpose, I'm sold. Do you really need a study to back up common sense in this instance? If you have a respiratory patient who is toeing the line of respiratory arrest, do you really want to risk making them worse? Disassociate them. They'll either get better on BiPAP or they won't. It won't be the fault of the ketamine if they don't. If they don't, drop your tube and move on.


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## Brandon O (Nov 4, 2018)

Remi said:


> It isn’t really even a _risk_, because if you give someone a small dose of ketamine and they start to get a little crazy, there’s an easy fix.....more ketamine.





Fully dissociating someone on BiPap is a little bold. I know Weingart has been talking about that in the context of "DSI" but I don't think it would fly in my world.

My concern would be how long you're going to leave them like that; a lot of these COPD exacerbations need to be on the mask for hours, and I'm not sure what the endgame is -- leave them dissociated all day?


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## PotatoMedic (Nov 4, 2018)

Brandon O said:


> I'm not sure what the endgame is -- leave them dissociated all day?


Least they are having a good time trying to breath!


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## Brandon O (Nov 4, 2018)

PotatoMedic said:


> Least they are having a good time trying to breath!



Yeah, or their soul is leaking out from their pores and they're desperately trying to plug them up using telepathy.


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## Carlos Danger (Nov 4, 2018)

Brandon O said:


> Fully dissociating someone on BiPap is a little bold. I know Weingart has been talking about that in the context of "DSI" but I don't think it would fly in my world.



I'm not going to argue in defense of the idea because as I wrote before, I don't advocate for routinely sedating folks in severe respiratory distress.

All I said was _if_ the decision was made that the best course of management involved using some mild sedation to facilitate NIPPV, then ketamine was probably the best choice, and _if_ the initial dose of ketamine caused agitation, a little more would fix that. 



Brandon O said:


> My concern would be how long you're going to leave them like that; a lot of these COPD exacerbations need to be on the mask for hours, and I'm not sure what the endgame is -- leave them dissociated all day?



Generically, my plan would be to use a low-dose ketamine infusion or small periodic boluses along with very small doses of a benzo or a-agonist, until respiratory status started to improve, at which point I would gradually decrease the dose of first the ketamine, and then the benzo. Hopefully, as they start to wake up their anxiety would have improved. If it did not, then you'd have to choose whether to toss them back in the hole, or intubate. That decision would be heavily influenced, of course, on the progression of their exacerbation.



Brandon O said:


> Yeah, or their soul is leaking out from their pores and they're desperately trying to plug them up using telepathy.



You seem really concerned about the hallucinogenic effects of ketamine. To be blunt, it isn't that big of a deal. Most folks have no explicit recall of it at all, especially if they were very physiologically stressed at the time. Some who do have recall actually enjoy it. Others remember a very strange, but not at all distressing experience. Relatively few people have the classic "bad trip" that they find very distressing. And all it takes to substantially reduce the chance of an unpleasant experience is a little GABA enhancement or Alpha agonism. There's a lot of research in the anesthesia literature on the topic.


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## TXmed (Nov 4, 2018)

How about this question. If you're a MD at an ER and are told EMS is bring in a patient in sever respiratory distress. They arrive with a patient with significantly decreased GCS, maybe from ketamine or maybe from hypercapnia, on BiPAP/CPAP.

Do you ride with that or do you take their airway ?


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## VFlutter (Nov 4, 2018)

TXmed said:


> How about this question. If you're a MD at an ER and are told EMS is bring in a patient in sever respiratory distress. They arrive with a patient with significantly decreased GCS, maybe from ketamine or maybe from hypercapnia, on BiPAP/CPAP.
> 
> Do you ride with that or do you take their airway ?



Very situation dependent. I've sat on sedated or severely obtunded BiPAP patients in the ICU and it can be sketchy at times. Usually frequent flyers who were known to be difficult to wean from the vent or terminal patients that should not be full code. It can be done but tends to be resource intensive and probably better off intubating most of them.


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## E tank (Nov 4, 2018)

TXmed said:


> How about this question. If you're a MD at an ER and are told EMS is bring in a patient in sever respiratory distress. They arrive with a patient with significantly decreased GCS, maybe from ketamine or maybe from hypercapnia, on BiPAP/CPAP.
> 
> Do you ride with that or do you take their airway ?


 
I get a blood gas for starters.


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## PotatoMedic (Nov 5, 2018)

E tank said:


> I get a blood gas for starters.


Blood gasses drive respiratory management.


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## Brandon O (Nov 5, 2018)

Remi said:


> Generically, my plan would be to use a low-dose ketamine infusion or small periodic boluses along with very small doses of a benzo or a-agonist, until respiratory status started to improve, at which point I would gradually decrease the dose of first the ketamine, and then the benzo. Hopefully, as they start to wake up their anxiety would have improved.



Fair. For myself, I would be more comfortable using Precedex for this. For us that would mean an ICU admission versus a lower level of care -- but so would ketamine, and either way such a patient probably needs the ICU.



> ... Relatively few people have the classic "bad trip" that they find very distressing.



I wonder if this differs in the ED/ICU setting versus the anesthesia population, though. One supposes the latter is better primed with a calm, controlled environment to accept unusual sensations or experiences with equanimity. I haven't seen many critically ill patients for whom perturbations in their sensory experience would be welcome, particularly if they're already anxious.



> And all it takes to substantially reduce the chance of an unpleasant experience is a little GABA enhancement or Alpha agonism.



I certainly throw in a benzo if/when they're having a hard time. Do you do it prophylactically when using ketamine?


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## Brandon O (Nov 5, 2018)

TXmed said:


> How about this question. If you're a MD at an ER and are told EMS is bring in a patient in sever respiratory distress. They arrive with a patient with significantly decreased GCS, maybe from ketamine or maybe from hypercapnia, on BiPAP/CPAP.
> 
> Do you ride with that or do you take their airway ?



Blood gas. If significantly hypercarbic, likely intubate. If normal... well honestly I think in most centers they'd still get intubated, but if it's somewhere that's trying to implement this notion of ketamine-assisted NIBBP, then maybe they could have a trial of that.


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## RocketMedic (Nov 5, 2018)

I'd edge more towards intubation than not.


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## Carlos Danger (Nov 5, 2018)

Brandon O said:


> Fair. For myself, I would be more comfortable using Precedex for this. For us that would mean an ICU admission versus a lower level of care -- but so would ketamine, and either way such a patient probably needs the ICU.



Precedex would probably work great for this. Personally, I'd need a really good reason to try to avoid intubation before I'd be starting several sedating infusions on someone just to facilitate NIPPV, though.



Brandon O said:


> I wonder if this differs in the ED/ICU setting versus the anesthesia population, though. One supposes the latter is better primed with a calm, controlled environment to accept unusual sensations or experiences with equanimity. I haven't seen many critically ill patients for whom perturbations in their sensory experience would be welcome, particularly if they're already anxious.


I doubt the setting matters at all. There's also a lot of data supportive of ketamine use in the ED setting.

The anxiety that you keep referring to is really a non-issue. In my practice I see a very high proportion of morbidly obese patients with OSA, so I use a LOT of ketamine for procedural sedation for brief procedures and sometimes as the primary anesthetic for bigger procedures. I have only occasionally seen it induce or worsen anxiety and adding more ketamine or 1-2mg of versed has never failed to fix it.

Not that long ago I gave a 230kg guy with severe Pickwikian syndrome 500mg of ketamine for an "awake" intubation and then nothing else but local for a painful I&D that took about a half hour. He breathed well on PSV the whole time, and after the case I gave him a couple mg of versed and extubated him to CPAP sitting straight up and when he finally woke up (which admittedly took a long time) he was fine and had no complaints.



Brandon O said:


> I certainly throw in a benzo if/when they're having a hard time. Do you do it prophylactically when using ketamine?



I used to never give ketamine without a benzo or propofol, but more and more, I use it alone.

For preoperative nerve blocks, I used to mix 2cc (50mg) of ketamine in a syringe with 2cc (2mg) of versed and push 1-2cc as needed. This worked awesome, but then patients would occasionally be too sleepy after the block to interact with the surgeon or their family before their operation, plus I don't like using versed in older patients anyway. So I started using propofol plus ketamine. This worked better, but in an effort to keep things simpler and cleaner, I started using just ketamine. Now I usually give just a 25mg dose of ketamine and get a still, calm patient for the 10 minutes or so that I need them that way. Often they'll talk to me, sometimes not but usually about 20 minutes after I give it, they are pretty lucid. Sometimes I end up giving 50mg. Never had an issue with increased anxiety or a bad trip.


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## Brandon O (Nov 6, 2018)

Thanks Remi.


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