# CPAP: When To Pull The Trigger



## EMSrush (Nov 5, 2011)

I realize that protocols and equipment vary greatly from service to service when it comes to using CPAP. For those who use CPAP, I'd like to know what your own (personal or protocol) criteria for pulling the trigger and taking out the CPAP, as opposed to utilizing alternative means or simply supportive care. 

Also, what pharmaceutical options to do you have available to use in conjunction with or in lieu of CPAP?

Thanks for the feedback.


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## Shishkabob (Nov 5, 2011)

Honestly, I wouldn't label it as "pulling the trigger" with CPAP as that gives the connotation that it has a relatively high risk, ala RSI.


If they're in distress or failure, conscious, and maintain their own ventilations, it's an option in my head.  If I'm thinking intubation on a conscious patient, I'm contemplating CPAP first.  Might work, might not.  My current agency doesn't allow it for asthma, (even though they admit some studies back it up) but I have given it for asthma (previous agency), COPD, CHF, and other disease processes before.



Drugs in conjunction with?  Like Captopril / Enalapril and nitro for CHF?  Yes, I have those options.


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## fast65 (Nov 5, 2011)

For me, it's not a terribly difficult decision to pull the trigger on CPAP (not implying it's difficult for others). If I have a patient with crappy lung sounds, who is still decompensating/not improving with my current treatments then I pull the trigger. As far as meds go, we have furosemide, bemetanide, nitro, and morphine.

I haven't actually put it into those terms (intubation on a conscious person = CPAP trial) Linuss, I like that.


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## usalsfyre (Nov 5, 2011)

When to pull the trigger in CPAP? Early and often. I regularly use pharmacology in conjunction with it.


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## DrParasite (Nov 5, 2011)

my former medical director wanted to give CPAP to the BLS providers as well :unsure:


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## Shishkabob (Nov 5, 2011)

DrParasite said:


> my former medical director wanted to give CPAP to the BLS providers as well :unsure:



Why not?  At my current agency, Intermediates and up can do it (with EMTs assisting medics on its setup), however EMTs are getting access to it in the next revision of the protocols so they can do it on their own without a medic being there.


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## EMSrush (Nov 5, 2011)

My agency is a non-RSI/MFI agency. We cannot use CPAP on asthmatics, but it's ok to use it on CHF Pts on standing orders, and COPDers after contacting MedCon.


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## usalsfyre (Nov 5, 2011)

I see lots of agencies misunderstand the role of NIPPV in asthma...


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## Handsome Robb (Nov 5, 2011)

What are your thoughts on CPAP in conscious burn patients with impending airway compromise? While you setup RSI or NTI in my case since NV doesn't allow medics to perform RSI 

We don't carry CPAP here. We are "high and dry" environmentally so we don't have too many CHFers here unless they are just up for the weekend. We use BVM + a PEEP valve if we need it so I don't have any experience with CPAP/BiPAP. With that said I'll agree with early administration. It's non-invasive so if the pt will tolerate it why not jump on it before you end up chasing your tail?


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## Shishkabob (Nov 5, 2011)

The problem with airway burns is the edema in the trachea causing it to shut tightly.  We want a tube in there before it does, because then the only thing you can do is a cric and hope for the best.

CPAP won't help there because it isn't physically keeping the airway open, like a plastic ETT does.   



CPAP is used in CHF because when the fluid enters the interstitial space, it pushes against the alveoli. causing them to get smaller, and as such, the surface area for gas exchange to decrease.  CPAP splints those open by putting more pressure in the airways than the pressure from the fluid.  It also hopefully keeps more fluid from entering the 3rd space by being higher than the pressure in the blood vessels surrounding the alveoli.


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## Handsome Robb (Nov 5, 2011)

Linuss said:


> The problem with airway burns is the edema in the trachea causing it to shut tightly.  We want a tube in there before it does, because then the only thing you can do is a cric and hope for the best.
> 
> CPAP won't help there because it isn't physically keeping the airway open, like a plastic ETT does.
> 
> ...



That makes sense. I understand the science behind CPAP, I wasn't sure if it was a reasonable intervention to utilize in a situation such as the one I presented. We really are stuck with airway burn patients here without RSI, we can perform nasotracheal intubations, but to be honest I am not comfortable with it, we've talked about it plenty, my big issue is I never have once performed one on a patient or a mannequin. Even our flight service can't get a proper RSI protocol due to our state EMS office. They call it "medication assisted intubation". They still use paralytics and sedatives but since the state wont allow RSI they leave out some of the meds to make it a true RSI. 

My wonder is how CPAP works in asthmatics? These patient's are suffering from an acute bronchoconstriction secondary to an exacerbation of their asthma, not fluid within the alveoli. Where does CPAP/BiPAP come into the picture in these patients?


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## fast65 (Nov 5, 2011)

NVRob said:


> That makes sense. I understand the science behind CPAP, I wasn't sure if it was a reasonable intervention to utilize in a situation such as the one I presented. We really are stuck with airway burn patients here without RSI, we can perform nasotracheal intubations, but to be honest I am not comfortable with it, we've talked about it plenty, my big issue is I never have once performed one on a patient or a mannequin. Even our flight service can't get a proper RSI protocol due to our state EMS office. They call it "medication assisted intubation". They still use paralytics and sedatives but since the state wont allow RSI they leave out some of the meds to make it a true RSI.
> 
> My wonder is how CPAP works in asthmatics? These patient's are suffering from an acute bronchoconstriction secondary to an exacerbation of their asthma, not fluid within the alveoli. Where does CPAP/BiPAP come into the picture in these patients?



What meds are they missing?


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## usalsfyre (Nov 5, 2011)

Think about what positive pressure may do to a patient with decreasing tidal volumes due to fatigue of the muscles of respiration. 

Understand bilevel NIPPV is really a better choice here, but there's not a generator really suited to EMS use outside of some REALLY expensive transport vents.


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## DrankTheKoolaid (Nov 5, 2011)

*re*

^_^Agreed.  Cpap is great early on in the asthmatic in conjunction with the B2 inhaled agonists.  Once patient becomes fatigued and desaturates CPAP has less use as they have all the end expiratory pressure pressure they can handle (and then some by the amount of fatigue).  They now really need inspiratory pressure support to assist with their failing fatigued lungs.


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## BEorP (Nov 5, 2011)

NVRob said:


> My wonder is how CPAP works in asthmatics? These patient's are suffering from an acute bronchoconstriction secondary to an exacerbation of their asthma, not fluid within the alveoli. Where does CPAP/BiPAP come into the picture in these patients?



Since asthma is an obstructive airway problem, I would think it probably would have a similar mechanism to CPAP for COPD (which relates to preventing dynamic airway collapse). If you PM me your email I can send you an article on it that you might find interesting.


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## fast65 (Nov 5, 2011)

BEorP said:


> Since asthma is an obstructive airway problem, I would think it probably would have a similar mechanism to CPAP for COPD (which relates to preventing dynamic airway collapse). If you PM me your email I can send you an article on it that you might find interesting.



If you could pm that to my account here too, I would appreciate it 


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## exodus (Nov 5, 2011)

Just post it here...


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## fast65 (Nov 5, 2011)

exodus said:


> Just post it here...



I was thinking that after I posted, but I was just a little too lazy to say it 


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## Yarbo (Nov 6, 2011)

In Canada here EMTs "PCPs" can do CPAP  Feel bad for the other EMTS in different places that cant.


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## fast65 (Nov 6, 2011)

This whole thread has kind of reminded me that I haven't had a respiratory distress call in a long time, perhaps tomorrow?


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## the_negro_puppy (Nov 6, 2011)

BLS & ALS here has no CPAP :wacko:


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## fast65 (Nov 6, 2011)

the_negro_puppy said:


> BLS & ALS here has no CPAP :wacko:



That's kinda odd


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## SanDiegoEmt7 (Nov 6, 2011)

Here CPAP is used for severe respiratory distress in asthmatics, COPD, and CHF.  Being that it's only or severe SOB, it's always used in conjunction with meds, because at that point we are generally giving them almost everything we have.  Whether it's nitro, albuterol, Epi, mag sulfate, etc. 

We don't have RSI or MFI.  It's a great device.  I've seen it do wonders for patients.


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## BandageBrigade (Nov 6, 2011)

I'm kind of shocked by the number that do not or cannot use for asthma and do not use in-line nebs


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## rhan101277 (Nov 6, 2011)

I bet CPAP isn't to effective at high pulmonary blood pressures.


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## Smash (Nov 6, 2011)

BandageBrigade said:


> I'm kind of shocked by the number that do not or cannot use for asthma and do not use in-line nebs



I don't see why you would be shocked when you consider the dearth of good evidence for CPAP in asthma.


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## Shishkabob (Nov 6, 2011)

BandageBrigade said:


> I'm kind of shocked by the number that do not or cannot use for asthma and do not use in-line nebs



That's the thing, we have inline nebs with A&A with CPAP in COPD exacerbation, but not asthma, when in reality, asthma and COPD aren't too dissimilar.


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## BandageBrigade (Nov 6, 2011)

Smash said:


> I don't see why you would be shocked when you consider the dearth of good evidence for CPAP in asthma.



But the evidence is there. Much of it is newer, but it shows to be much more effective than originally tonight. I will have to post some of the studies after I get off work.


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## Handsome Robb (Nov 6, 2011)

fast65 said:


> What meds are they missing?
> 
> 
> Sent from my iPhone using Tapatalk



There's no defascultating dose of vec when sux is used as the paralytic, there's no atropine to prevent bradycardia, however it can be considered if the patient becomes bradycardic and there's no lidocaine used in patients with suspected increased ICP/head injury. 

They can give Midazolam OR Etomidate, then Fentynal, can attempt intubation at this point or move to Succinylcholine OR Vecuronium. Then Vecuronium for continued paralysis. 

I know the fent can combat spikes in ICP.

So I guess it is actually an RSI. h34r:


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## usalsfyre (Nov 6, 2011)

Defac doses, atropine in adults and lido for ICP are all in doubt/have been disproven. The only thing I saw that was weird is the fent and etomidate are backwards.


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## Shishkabob (Nov 6, 2011)

Atleast they are stupid to the point of allowing Etomidate but no paralytic like some places.


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## Handsome Robb (Nov 6, 2011)

Linuss said:


> Atleast they are stupid to the point of allowing Etomidate but no paralytic like some places.



:unsure: I don't quite understand what your getting at.


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## Shishkabob (Nov 6, 2011)

NVRob said:


> :unsure: I don't quite understand what your getting at.



Some places think Etomidate and etomidate only without a paralytic as a backup constitutes as a 'smart idea' and 'PAI'.  Etomidate is well known to cause trismus on occasion... and if you don't have a paralytic to combat it, your patient is screwed.



Sure, just etomidate can work at times, and can actually be a good idea if you're fearful of a tougher intubation than normal and dont want to risk the paralysis, but if you have no backup aside from cutting a hole in their neck, you're in a world of hurt when they finally lock down.  My second RSI, I tried to just do etomidate without Roc, and he locked down.  Luckily I had the fore-site of having my Roc already pulled up just in case.  Gave it, loosened up, got the tube and all was good.


PS--- I originally meant "aren't" stupid, not are.  My bad!


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## Fish (Nov 7, 2011)

I am personally pretty liberal when it comes to CPAP(given the patient has no contraindications to it)

CPAP is a wonderful tool that works very well, and in a lot of areas is listed as a BLS skill.


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## systemet (Nov 7, 2011)

Regarding etomidate (-succinylcholine), here's an abstract for a study comparing etomidate alone versus etomidate + sux for intubation by a HEMS system.

They had to use "rescue succinylcholine" in 11% of patients given etomidate alone.






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Am J Emerg Med. 2000 Nov;18(7):757-63.
Etomidate versus succinylcholine for intubation in an air medical setting.
Kociszewski C, Thomas SH, Harrison T, Wedel SK.
Source

Boston Medflight Critical Care Transport Service, MA, USA.
Abstract

The objective was to compare rates of successful endotracheal intubation (ETI) and requirement for multiple ETI attempts in patients receiving etomidate (ETOM) versus succinylcholine (SUX). This retrospective study analyzed adults in whom oral ETI was attempted by a helicopter EMS (HEMS) service between July 1997 to July 1999. Data were from records of the HEMS service, which uses a RN/EMTP crew; analysis was with chi-square and logistic regression (P = .05). ETI was successful in 269 (97.8%) of 275 patients, with multiple attempts occurring in 54 (20.1%) of 269. Success rates for SUX (209 of 213, 98.1%) and ETOM (60 of 62, 96.8%) were similar (P = .62). However, of 60 ETOM patients successfully intubated, 7 (11.7%) required rescue succinylcholine. When these patients are tallied as ETOM failures and SUX successes, resultant success rates for ETOM (86.9%) and SUX (98.2%) are different (P = .001). ETOM patients were more likely (P = .004) than SUX patients to require multiple attempts (33.3% versus 16.3%). ETI success rates were high in patients receiving SUX or ETOM as primary adjuncts for airway control, but initial success was more likely with SUX, and ETOM patients were more likely to require multiple attempts.

PMID:
    11103724
    [PubMed - indexed for MEDLINE] 

Publication Types, MeSH Terms, Substances
LinkOut - more resources


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