# EMS-Friendly BiPAP?



## FiremanMike (Jun 13, 2017)

Is anyone out there aware of any EMS oriented BiPAP machines on the market?  The only units I have seen outside of the hospital are all-in-one vent/cpap/bipap machines that were too complicated for most users.

Certainly there must be something out there?

Thanks in advance!


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## hometownmedic5 (Jun 13, 2017)

So instead of raising competence, we simplify procedures so anybody can do it.

:smh:

A better argument is that the vents that do bipap are too expensive due to having unnecessary features for the emergent setting. At least with that argument, we aren't dumbing down our practice, we're being budget conscious. 

And no, I don't know of an EMS friendly BiPap device.


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## VFlutter (Jun 13, 2017)

Why would you not want a vent? So you are going to  place the patient on Bipap and then if they get intubated you just bag them until you get to the hospital? 

Get a Revel and get some training.


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## FiremanMike (Jun 13, 2017)

We have <5 minutes to the ER, it is rare that we progress from CPAP to RSI, I imagine that BiPAP usage will pan out similarly.  

I don't need a vent, I need a simple to use BiPAP machine.


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## VentMonkey (Jun 13, 2017)

FiremanMike said:


> We have* <5 minutes to the ER*, it is rare that we progress from CPAP to RSI, I imagine that BiPAP usage will pan out similarly.
> 
> I don't need a vent, I need a simple to use BiPAP machine.


You don't _need_ BiPAP for a (<) 5 minute transport to the ED.


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## GMCmedic (Jun 13, 2017)

VentMonkey said:


> You don't _need_ BiPAP for a (<) 5 minute transport to the ED.


This

Sent from my SAMSUNG-SM-G920A using Tapatalk


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## hometownmedic5 (Jun 13, 2017)

Chase said:


> Why would you not want a vent? So you are going to  place the patient on Bipap and then if they get intubated you just bag them until you get to the hospital?
> 
> Get a Revel and get some training.



Naturally I can't speak for anywhere but here, but in MA, We can't initiate mechanical ventilation in the field; so I get not having a vent on a 911 truck if they have the same policy.


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## FiremanMike (Jun 13, 2017)

I would like an intermediate option for our COPD patients that are refractory to CPAP.


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## NomadicMedic (Jun 13, 2017)

How about a little sedation?


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## ThadeusJ (Jun 13, 2017)

A non-vent Bilevel (as BiPAP is actually a brand name of a Respironics product) is still in the future (I'm convinced the technology, knowledge and materials are out there,) but there still isn't a small, oxygen conserving device Bilevel on the market.  It should also be note that (as far as I have seen), there are no verified studies that show that Bilevel has better patient outcomes than straight CPAP.

Trying to get one of those disposable CPAP devices to offer Bilevel is the golden egg.


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## VentMonkey (Jun 13, 2017)

FiremanMike said:


> I would like an intermediate option for our COPD patients that are refractory to CPAP.


Other than this, can you elaborate and justify why you absolutely need a Bi-level device for such a short ETA? 

Most prehospital CPAP's aren't equipped to handle BiPAP, and are disposable. An actual ventilator is most likely your only other option.


NomadicMedic said:


> How about a little sedation?


Also, this^^^. It seems much more practical for your service, but only you'd know best.


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## NomadicMedic (Jun 13, 2017)

And honestly, if they're not responding well to CPAP, they'll probably buy a tube.


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## VentMonkey (Jun 13, 2017)

Not for nothing, but the OP's thread title indicates that the BiPAP would need to be "EMS friendly", which to me screams watered down.

Now, there isn't a whole lot of critical thinking that goes along with understanding IPAP, EPAP, airway pressures, and the like, but it sounds as if a watered down BiPAP is useless without a bit more education of the advanced airway variety. Again, hardly a dig at anyone, but Bi-level airway pressures and their mechanics isn't something taught in most (basic) paramedic schools. 

Should, or could it be? Absolutely, but just because you want some more intermediate (by the way, again, please share with us your reasoning and rationale for wanting such a device) airway pressure device for 5 minutes doesn't mean the cost allocations, let alone medical justifications are or would be warranted.

So, again, why would any standard ALS service need BiPAP vs. CPAP? If anything maybe you could justify purchasing ventilators for the entire department, upping the departments airway knowledge, take on vent-dependent IFT's, and recoup some money that way. Then you'd also have a machine capable of delivering BiPAP.


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## CWATT (Jun 14, 2017)

I'm new to mechanical ventilation, but is there really any benefit to BiPAP for paintents with symptoms refractory to CPAP? It's my understanding the primary benefit to BiPAP is patient comfort (allowing them to exhale against a lower pressure).


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## FiremanMike (Jun 14, 2017)

There was a time when I would have fervently agreed with all of you, and in the back of my truck such a patient would have been likely to have received some rocketamine and a tube.

My role now is different and I have a much more in depth understanding of the knowledge/skill base of the providers at my department as well as a different understanding of what is done once these patients arrive at the hospitals.  PCRs that I review where I say "grr, why wasn't this pateint RSI'd, certainly they were emergently intubated in the ED" are nowhere near as frequently intubated in the ED as I would have previously thought/expected.

I had done my own google searches prior to posting this thread and was unable to find a device short of a full ventilator that will allow for BiPAP, but I was hoping someone on here had come across the "golden egg" as was previously mentioned.  While it is a lofty goal to state that all EMS providers should, given the right training, become competent and confident with the transport ventilators on the market, I believe it underestimates the complexity of these units.  Excluding those of you that are working in critical care settings, can you honestly say that you'd be comfortable throwing a Zoll 731 on the trucks and be confident that all of your providers would be competent in how to use it?  For me personally, it took a great deal of effort to learn and feel comfortable with the transport ventilators that I have used.  This a skill set that requires personal motivation to stay current, which is something that (if we're being honest with ourselves) isn't as prevalent in EMS as it should be.

My desire for a BiPAP is for obstructive airway exacerbations where CPAP isn't cutting it and inspiratory pressure support would be beneficial.  I am no longer an "RSI everyone" guy, but I'm also not a "No one should get RSI'd in the field" guy either.  With that said, if we can prevent an RSI through less invasive means, I think we should make an effort at doing so.  My understanding of BiPAP as well as what I've been able to gather from care these folks are receiving in the ED is that BiPAP could be that answer.


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## VentMonkey (Jun 14, 2017)

Here's a quick read relevant to this thread:

http://www.emsworld.com/article/12145134/evidence-based-ems-out-of-hospital-bipap-vs-cpap

@FiremanMike I'm not sure if you've read this piece or not, but I would wager to guess most of us on here agree with your level of airway management aggression.


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## ThadeusJ (Jun 14, 2017)

CWATT said:


> I'm new to mechanical ventilation, but is there really any benefit to BiPAP for paintents with symptoms refractory to CPAP? It's my understanding the primary benefit to BiPAP is patient comfort (allowing them to exhale against a lower pressure).


Actually the role of Bilevel is to increase the inspiratory support (thus decreasing the inspiratory Work of Breathing, or WOBi) while maintaining the baseline lower pressure which would otherwise be provided in your CPAP setting (recruiting alveoli by increasing the expiratory Work of Breating, or WOBe).  

The goal of preventing intubation rates using a non-invasive device has long been established in hospitals and thankfully now in the pre-hospital community.  10-15 years ago when it was first introduced to EMS (10 years max in Canada), a lot of hospital based healthcare professionals were certain that this initiative would crash and burn.  Its unfortunate that the degree of respiratory distress seen in patients is such a huge grey area that you see immediate results with the not-so-bad patients (accompanied by the "Why are you bringing this patient here, they're fine" pushback) while also seeing a futile attempt to buy a tube for those patients who waited a few too many days before calling ya'll.  I'm glad it seems to be working and is still expanding to BLS services across North America.  

I would _love_ to see an updated economic impact statement on its use.


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## FiremanMike (Jun 14, 2017)

VentMonkey said:


> Here's a quick read relevant to this thread:
> 
> http://www.emsworld.com/article/12145134/evidence-based-ems-out-of-hospital-bipap-vs-cpap
> 
> @FiremanMike I'm not sure if you've read this piece or not, but I would wager to guess most of us on here agree with your level of airway management aggression.



I've started that article 3x but I invariably get pulled away.  I will shut my door in a  bit and read through it, thanks for the reminder


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## NomadicMedic (Jun 14, 2017)

I guess the question is, would you feel more comfortable recommending a bit of sedation be provided than putting a ReVel on the truck?

With 5 minute transports, if you're not looking for a vent, I think you might out of luck. If CPAP isn't the answer, then you'll need to find a workaround. I still say a bit of versed makes the process of CPAP for an anxious patient significantly more palatable and usually fixes the issues that i have with compliance.


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## FiremanMike (Jun 14, 2017)

NomadicMedic said:


> I guess the question is, would you feel more comfortable recommending a bit of sedation be provided than putting a ReVel on the truck?
> 
> With 5 minute transports, if you're not looking for a vent, I think you might out of luck. If CPAP isn't the answer, then you'll need to find a workaround. I still say a bit of versed makes the process of CPAP for an anxious patient significantly more palatable and usually fixes the issues that i have with compliance.



It's not a matter of CPAP compliance, but the physiological differences between obstructive airway issues which would benefit from inspiratory pressure support versus CHF which only really needs increased PEEP.


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## NomadicMedic (Jun 14, 2017)

FiremanMike said:


> It's not a matter of CPAP compliance, but the physiological differences between obstructive airway issues which would benefit from inspiratory pressure support versus CHF which only really needs increased PEEP.



But in all honesty, is that a concern in a 5 minute transport? 

I hate EMSworld as a source, but that piece makes it pretty clear, "the studies reviewed in this article have not shown a clear or consistent advantage to BiPAP over CPAP in clinically significant outcomes such as decreased mortality, need for intubation, ICU admission and length of hospital stay."


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## FiremanMike (Jun 14, 2017)

NomadicMedic said:


> But in all honesty, is that a concern in a 5 minute transport?
> 
> I hate EMSworld as a source, but that piece makes it pretty clear, "the studies reviewed in this article have not shown a clear or consistent advantage to BiPAP over CPAP in clinically significant outcomes such as decreased mortality, need for intubation, ICU admission and length of hospital stay."



Well, that question is one that I honestly can't answer.  I feel like it may make a difference and I feel like we (collectively, not you and I) had similar debates at the early points of CPAP coming in to the EMS world..


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## Carlos Danger (Jun 14, 2017)

I don't think there is anything wrong with preferring equipment that is simple to use.

We used to transport people on CPAP and since we didn't carry a stand-alone CPAP device, we had to use our LTV1200. Anyone who has used an LTV for CPAP knows that it isn't the most user-friendly device for that purpose. There is a little bit of jerry-rigging involved and it is hard to keep the machine from alarming. At least it was with the circuits we had.

Anyway, I would have loved to have a CPAP device that was easier


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## RocketMedic (Jun 18, 2017)

FiremanMike said:


> I would like an intermediate option for our COPD patients that are refractory to CPAP.



In all honesty? I think that a BVM with a PEEP valve you can connect to your CPAP mask in lieu of the provided BVM mask is going to be the most effective 'BiPap' answer that you are going to get without buying a vent. It's fairly intuitive for any provider to figure out, easy to set and it is very rapid to configure.n One can also wire in an in-line nebulizer pretty easily. 

We had the Impact vent for CPAP and BiPap at EMSA and I honestly find the Flowsafe direct-O2 CPAP masks and the Pulmodyne yellow boxes to be more effective, although they are CPAP only. Coaching people onto BiPap in a prehospital setting is possible, but a lot of the vents out there come with a lot of alarms and proprietary tubing that makes actually applying them to anxious, tachypneic patients who need NIPPV quickly difficult. For example, the Impact was challenged when providing BiPap to patients breathing 40ish times a minute because it was nearing the limits of how fast it could cycle and our training was inadequate at best. Knowing now what I know, I'd take the 'ghetto BiPap' BVM and a PEEP valve and an in-line nebulizer kit over that contraption any day. 

Here's some videos that demonstrate the concept.


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## FiremanMike (Jun 19, 2017)

Very interesting, nice find!


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## gamedic87 (Jul 7, 2017)

At this point it's risk vs reward from a business stand point. Would it be ideal for every truck to have a legitimate transport vent and someone who knows how to use it? Absolutely! But that would also cost a moderately sized service hundreds of thousands and a boatload of training hours. It just doesn't seem feasible to field them on 911 trucks. It would take far too long to see a return on investment, and unless you work for a city/county service that means you're out of a job. Government is the only business that can consistently operate in the red.


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## RocketMedic (Jul 10, 2017)

BVM + a PEEP valve also helps with intubated patients who need PEEP.


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## ThadeusJ (Jul 10, 2017)

Although the BVM + PEEP valve would create the pressure differential, one of the advantages of a CPAP device is the constant flow which decreases the inspiratory work of breathing.  The _lack_ of that flow when using the BVM method minimizes the expiratory work of breathing as there is nothing to breathe out against.  Because the two flows add up to total work of breathing, the elimination of one over the other is difficult to choose.


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## VentMonkey (Jul 10, 2017)

@ThadeusJ I believe @RocketMedic was simply making reference to placing a PEEP valve on the BVM to ventilate an unconscious, intubated patient.Your reference seems more along the lines of the thread topic with regards to CPAP as an NIV method of use. 

The flow you make reference to would at this point (unconscious/ intubated) render said patient more-than-likely ventilator dependent, allowing for passive oxygenation and ventilation of inspiratory, and expiratory flow respectively.


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## ThadeusJ (Jul 10, 2017)

'Tis true, what you say, but I have seen this being used as a substitute to CPAP (but having to create a seal on a non-tubed pt creates more of a hassle than just using a device). 

Many years ago, there was the philosophy of "physiologic PEEP" that stated that the epiglottis created 2.5-5 cmH2O PEEP on its own and the act of intubation therefore bypasses and eliminates it.  Therefore, it was felt that the act of intubation automatically required PEEP at the bare minimum.  I have uncovered a paper from 1984 that questioned this logic and am unsure whether it is still an urban myth or something that has more bona fide research behind it (but I know its still standard practice in the hospitals). Regardless, a PEEP valve (and for gosh sales, please add a filter to the BVM) should be standard issue.


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## RocketMedic (Jul 10, 2017)

I was definitely talking about what @ThadeusJ was. One can even use a CPAP mask to maintain an airtight seal and attach a BVM with a duckbill valve and a PEEP valve to create low cost ghetto bipap.


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## SpaRTY047 (Jul 29, 2017)

Forty + years as a registered respiratory therapist and now here at a rural critical access hospital with some thoughts on this very subject:

We RTs put AECOPD patients (or CHF/pulm edema patients) in AcRespInsufficiency on Bilevel machines  specifically engineered for a high baseline (called bias) gas flow.  This allows us to more easily "capture the patient's WOB."   We then adjust IPAP and EPAP and rise time and inspiratory and expiratory time parameters to off load the WOB from the patient's fatigued muscles of respiration over to the "BiPAP" machine.

However these patients must be transferred to the "big city hospital critical care" which means we must attempt to "match settings" on the LTV 1200.    All too often the difference in technology induces panic and anxiety in a patient who's settled down nicely over the last 30 - 90 minutes on the non-invasive ventilator in bilevel mode.    Simply put, the LTV is engineered to conserve oxygen cylinder contents......this  strategy does not allow use of a bias flow.  Lack of bias flow results in enough delay in sensing that the patient is switching between exhalation and inspiration (measurable in milliseconds!!!) that the mechanical support lags behind what the patient needs/demands/craves.

So  we place these patients on one of the disposable gas driven CPAP devices; a high flow venturi mask; or must sedate and invasively ventilate!! 

The market needs to respond to this need....even if it means someone developing a transport bracket onto which a Phillips Brand V60 NIPPV unit can be properly secured; in a fashion similar to what is currently available for the LTV.  The Phillips V60 already comes with enough internal battery supply to allow 15-20 minute intra-hospital transports without interrupting therapy.  A proper method for securing the unit within the rig would allow the transport team to plug into the DC-AC power inverter for the 20-60 minute transport.

You guys can learn these machines and we are certainly there in the ED to have fine tuned the device and report off to you.

Good luck to both our specialties in meeting this need......it certainly does exist.


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## VFlutter (Jul 29, 2017)

IIRC the Revel has bias flow up to 10 lpm.


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## SpaRTY047 (Jul 29, 2017)

Good Point!        Yes, I noted that....but their bias flow comes on in NIPPV for leak compensation at mask seal.   Devices similar to the V60 (even the older Vision BiPAP) use constant circuit bias flows of 30 - 70 LPM at all times.....and insp limb and exp limb flow sensors are engineered for immediate response to a flow differential caused by patient's insp or exp flow diverting from (insp) or adding to(exp) the flow differential.  It's the ability to detect and respond within milliseconds to very small changes in this high bias flow that gives these devices the advantage over the LTV and Revel.


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## VFlutter (Jul 29, 2017)

No doubt that stand alone hospital NIPPVs offer more features and improved tolerability but they are just not realistic for the transport environment due size, portability, and oxygen consumption. Especially in HEMS where space is at a premium and many new aircraft do not have LOx. 

Unfortunately for many patients it is either tolerate the Revel/LTV NIPPV or get intubated.


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## SpaRTY047 (Jul 29, 2017)

True that - brother 

Currently, even on 30 min ground transport.....it appears there's a safety concern with properly securing auxiliary equipment.

That's the basis of my statement that the only alternative until market demands lead to engineering of a smaller unit, seems to be to devise an anchoring system for the V60 (given that ground transport EMS has DC>AC  power inverter and H cylinders)

Pts on helos will still fit your second statement.


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## MunchkinMedic (Nov 21, 2017)

I’m not sure what they carry but I know AMR Maricopa carry’s Bipap from personal experience


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## grumpy1 (Nov 27, 2017)

Zoll Vent 731

BiPAP and vent


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## TransportJockey (Nov 27, 2017)

grumpy1 said:


> Zoll Vent 731
> 
> BiPAP and vent


Is that the zoll aev? We are using that on our 911 trucks and must of our crews like it. We are getting the emv plus for our micu transfer truck soon too


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## grumpy1 (Dec 1, 2017)

TransportJockey said:


> Is that the zoll aev? We are using that on our 911 trucks and must of our crews like it. We are getting the emv plus for our micu transfer truck soon too



Correct.  We have had good success with this vent on multiple aircraft with little problem.  Its a bit more affordable that the Revel, which is a great machine as well.


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