# CPAP vs intubation for CHF



## DrParasite (Sep 14, 2012)

a little backstory on this call:

i just started a new part time job, in a new county, for awesome pay in an area that's not all that busy.  It's a BLS  911 and IFT agency, handing BLS calls for the town and for calls meeting ALS criteria a paramedic flycar is requested from a hospital.

It was my first shift on the truck, and due to a scheduling snafu, I was assigned as a 3rd, instead of a 2nd.  I was also informally educated about how the ALS agency's crews aren't the nicest to BLS crews, and has a bad habit of walking in and asking BLS crews "so are we cancelled????" on every call, and really giving crews a hard time on calls that they are not cancelled for that that don't obviously need an ALS assessment or intervention.  Suffice it to say, I was a little disturbed by what I heard, but I'm a big boy, and every place has their quirks, so whatever.

and the night is dead.  slooooow.  we have 3 trucks on, and in 8 hours, neither truck has done anything.  i'm crawling the walls from boredom.  completely not used to this

Anyway, we get a call for a difficulty breathing.  pt is an elderly gentleman from another country with a language barrier who is found sitting on the floor with a nebulizer in his mouth recieving a treatment.  hx of copd, and htn, prescribed a combivent and htn meds which he hasn't taken all day.  Pt is grossly diaphoretic, w/ JVD present.  NRB is applied at 15 lpm, and patient immediately pulls it off.  

my working diagnosis at this point is that he's in heart failure, and his lungs are full of fluid (based on my experience that I have seen people with CHF act exactly like this after they have flashed, since they feel like they are drowning).  a quick BP is assessed, found to be 260+/140, and a listen to his lungs reveals rales all the way up on both sides.  He is still fighting the NRB, and we are trying to get him to have it stay on.  We get him into the stairchair, and carry him down the stairs to the ambulance, where the ALS are just arriving.

Now, I have a pretty sick patient, and don't want to deal with anyone asking me "so do you really need us?"  Thankfully the medic is someone who I have known for 5 years, have worked on a BLS 911 truck together, and doesn't have that attitude at all.  He asked for a report on what has happened, and what I think is going on, and I tell him, and they begin treating the patient

I'm thinking they are going to CPAP this (still conscious) patient.  They establish IV access, give lasix, followed by 2 nitro sprays.  still no cpap.  an OPA is inserted, and the patient doesn't tolerate it.  He is still sitting up on the cot w/ a gag reflex, and the paramedic says he is going to intubate the patient.  I asked him if he wants to try cpap, and he tells me because he won't tolerate the NRB, CPAP isn't an option.  They push versed and a sedative, and the medic does a face to face intubation, and we end up bagging the patient in a seated position until we get to the ER.

here are my questions: once you intubate a CHF patient w/ pulminary, should you lay the person down or keep them sitting up?  does it matter?  this is the first time i can recall bagging a sitting up person who was intubated.

on intubate vs CPAP, when is CPAP no longer an option on a conscious patient?  when intubated, can a patient be easily extubated, or will they be on a vent for a while?

is it standard practice on CHF people that if a patient can't tolerate a NRB to immediately go to intubation?

not bad for my first call at the new place, and it turned out to be the only call for all 3 trucks for all 12 hours of the shift.


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## 325Medic (Sep 14, 2012)

At least in P.A....First we don't go straight to Lasix. We start serial NTG's with 1 off the bat followed by 3 if the pressure is still over 180 systolic. Thats besides the point. Also in P.A., we use Etomidate (not at the 2 squads I work because the M.D. does not like the profile by itself / for another discussion. I would have tried CPAP first. In our S.O.P.'s, the pt. needs to be...breathing (duh.lol) cooperative and maintaining an airway. As we both know. If we coach the pt. with a little man handling for a lack of a better term, they do get better. If I may ask. The pt. WAS tubed, right. I would prolly lay him in the semi-fowlers. I have down that in the past. I have also seen the E.D. give a little benzo to calm the pt. down with CPAP but that is not in our S.O.P.'s for fear of resp. depression. I have given CPAP with the same presentation / held the mask to their face with the NTG given and they did get better. I am sure we all have out way of doing things I suppose. If you want to see P.A.'s S.O.P.'s / protocols, P.A. DOH has statewide protocols. Are you south or north Jersey?

325.


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## DrankTheKoolaid (Sep 14, 2012)

Lol that medic you describe lost any value as a medic and any validity to anything he tries to explain to you the second he put in a OPA in a conscious patient.  CPAP was totally appropriate and if he knew what he was doing he could have coached the patient to tolerate it along with valium/versed/ Insert whatever sedative you have to help him along.  

Lasix....... Cant say it was indicated without more HX/PX findings and ETA to hospital.


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## 325Medic (Sep 14, 2012)

Corky said:


> Lol that medic you describe lost any value as a medic and any validity to anything he tries to explain to you the second he put in a OPA in a conscious patient.  CPAP was totally appropriate and if he knew what he was doing he could have coached the patient to tolerate it along with valium/versed/ Insert whatever sedative you have to help him along.
> 
> Lasix....... Cant say it was indicated without more HX/PX findings and ETA to hospital.




Lasix is under Medcomm orders only now and will prolly be taken off the S.O.P.'s. We use lots of NTG and ACE inhibitors (enalapril) and that works. I have seen medics that are older than me (and I was taught this way years ago) that have given 200mg of Lasix and it turned out to be pneumonia also. Those same medics also complain when the D.O.H. takes meds. off the list. Such as Lasix and Atrpine for asystole. They don't look @ the reasoning behind it and still embace the year 1990.

325.


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## hibiti87 (Sep 17, 2012)

regards to the question of bagging while in the seated position. The patients issue was inadequate perfusion due to fluid in his lungs, bagging while in the seated position decreases the areas of the lungs affected by this fluid.


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## fast65 (Sep 17, 2012)

If the patient is conscious and alert, and they can maintain their airway, they should be put on CPAP. From where I'm standing, that patient was mismanaged. Just because a patient won't keep a NRB on, does not mean they aren't eligible for CPAP.

Like others have said, that patient should have been put on CPAP, and coached their breathing. A little Versed would have helped as well if it's allowed.


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## DrParasite (Sep 17, 2012)

hibiti87 said:


> regards to the question of bagging while in the seated position. The patients issue was inadequate perfusion due to fluid in his lungs, bagging while in the seated position decreases the areas of the lungs affected by this fluid.


I never thought of it that way.... makes sense.


fast65 said:


> If the patient is conscious and alert, and they can maintain their airway, they should be put on CPAP. From where I'm standing, that patient was mismanaged. Just because a patient won't keep a NRB on, does not mean they aren't eligible for CPAP.
> 
> Like others have said, that patient should have been put on CPAP, and coached their breathing. A little Versed would have helped as well if it's allowed.


I think (and I'm speculating, not a medic nor was it my call) the issue was that he was combative and probably hypoxic (with a language barrier, it was hard to tell how alert the patient was), hence the reason the choice was to intubate vs CPAP.  But I was thinking CPAP too, and was surprised when they went straight to intubation.


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## usalsfyre (Sep 17, 2012)

I might have tried a brief CPAP trial with some coaching. That said, anxiety, agitation and claustrophobia are suspicious for respiratory failure and enough to buy a tube. Without being there I'm not gonna second guess the guy.


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## fast65 (Sep 17, 2012)

DrParasite said:


> I never thought of it that way.... makes sense.
> 
> I think (and I'm speculating, not a medic nor was it my call) the issue was that he was combative and probably hypoxic (with a language barrier, it was hard to tell how alert the patient was), hence the reason the choice was to intubate vs CPAP.  But I was thinking CPAP too, and was surprised when they went straight to intubation.



I forgot about the language barrier, I suppose that is a bit more suspect for respiratory failure. However, I still think a trial of CPAP was warranted before pulling the trigger on intubation. I will admit though, that I probably shouldn't have said this patient was mismanaged, I let the initial description of the medics jade my opinion a bit.


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## medicsb (Sep 17, 2012)

Define this patients consciousness.  Talking or just eyes open?  I kind of have a hard time believing that anyone (medic or otherwise) would try to place an OPA in someone who is able to talk.  Part of me wonders if they had reason to believe that the patient lost consciousness.  Otherwise, it is certainly a "WTF" inducing action.  

As far as CPAP versus ETI... it can be a tough call for a patient in extremis and it sounds as if the patient may have been in that grey area where one could argue either way.  If the patient was that uncooperative (likely due to hypoxia), attempts at "coaching" will likely be futile.  I've found that once patients are tearing things off, they're usually (but not always) beyond the point of CPAP being helpful.  Is it worth letting the patient remain hypoxic while fighting to keep them on O2 (either via CPAP or NRB) while waiting for sedative to kick in (which could potentially put them into further respiratory failure) when you can have them out and paralyzed in a matter of seconds and bagging them while prepping for ETI?  Tough to say without having been there.

The face-to-face ETI was a pretty boss move, though.  

Sucks to hear about ALS' gneral treatment of BLS.


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## Christopher (Sep 17, 2012)

usalsfyre said:


> I might have tried a brief CPAP trial with some coaching. That said, anxiety, agitation and claustrophobia are suspicious for respiratory failure and enough to buy a tube. Without being there I'm not gonna second guess the guy.



Even if you elect to (properly) RSI this patient without CPAP first...you're still going to need to preoxygenate with a BVM. CPAP is just a handy BVM if they're breathing on their own.

If you have time for a versed intubation, you have time for versed/ativan + NTG + CPAP, no?


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## usalsfyre (Sep 17, 2012)

Christopher said:


> Even if you elect to (properly) RSI this patient without CPAP first...you're still going to need to preoxygenate with a BVM. CPAP is just a handy BVM if they're breathing on their own.


Depends. I've taken care of the patient where preoxygenation took place post-induction (think Braude's DAI without a King) because all other attempts failed.



Christopher said:


> If you have time for a versed intubation, you have time for versed/ativan + NTG + CPAP, no?


Ehhh, perhaps. I also know a lot of very good clinicians who get very nervous about giving a patient in respiratory failure a benzo without being ready to tube them. 

I'm not saying the other way is not superior if it works. Most of my fulminant CHF patients get 1.2mgs of NTG under the tongue, a CPAP mask and a NTG infusion. But I've also pulled the trigger on intubation early in the process before because things just didn't look right.


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## firecoins (Sep 17, 2012)

Its Jersey?  No wonder ALS expexts to be cancelled.


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## Christopher (Sep 17, 2012)

usalsfyre said:


> Depends. I've taken care of the patient where preoxygenation took place post-induction (think Braude's DAI without a King) because all other attempts failed.



I think I agree in practice, provided you've reached that point. Regardless, during the time it takes to setup for RSI/RSA at least some pre-ox can occur.




usalsfyre said:


> Ehhh, perhaps. I also know a lot of very good clinicians who get very nervous about giving a patient in respiratory failure a benzo without being ready to tube them.



It's much safer to give a low dose to chill them out than it is to perform a "facilitated intubation". Drug assisted intubation that isn't RSI/RSA has a much higher complication rate.



usalsfyre said:


> I'm not saying the other way is not superior if it works. Most of my fulminant CHF patients get 1.2mgs of NTG under the tongue, a CPAP mask and a NTG infusion. But I've also pulled the trigger on intubation early in the process before because things just didn't look right.



I too agree that early RSI/RSA is definitely indicated in your crashing Pulm Edema patient. I think we're on the same page.

My point was if you're going to intubate and a trial of CPAP didn't happen then you gave a benzo-OD (I'm sorry, "facilitated") before intubation...then it probably isn't being done right.


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## Trashtruck (Sep 17, 2012)

I can't criticize his decision. The guy sounds like he's circling the drain quickly with pulling the NRBM from the start.
Like 325 said, the struggling pt. may struggle against you as you struggle back to help them. You need to win that struggle for their sake(it may not be pretty, but...oh well. Sometimes 'coaching' the pt to leave the CPAP on isn't gentle)  
However, sometimes they are beyond the point of CPAP. My guess is that by the time you got the pt in the stairchair and got him out, all while not tolerating an NRBM coupled with being strapped to a chair and being jarred out of a house, he probably developed that stare off into space look that the medic recognized immediately and decided to forego the futile effort of placing the pt on CPAP. More of a cut-to-the-chase decision.

The OPA??? I have no clue what that was about.

Don't lay somebody down with pulmonary edema. I forget who said it, but you're just covering more surface area of the lungs with the bad stuff, leaving less lung to get the good stuff. I know, I know...spoken like a true professional!


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## ah2388 (Sep 18, 2012)

What medicsb said imo.

I think a trial of CPAP is warranted if at all possible, but this pt does appear to be deteriorating and I cant question the judgement of someone else without having more information and/or being there.


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## jroyster06 (Sep 18, 2012)

I would have tried a benzo with CPAP if that didnt work its time to intubate. I think it really comes down to pt presentation and transport time. Obviously pt presented as..... "crappy." Once they start the head bobbing thing its usually time to intubate and be ahead of the game rather than to have a crash airway situation. I have intubated the CHFer head bobbing and i have also started them on CPAP. Its hard to armchair this one because it all really depends on your gut feeling on presentation. And here we have a minimum transport of 45 min so we probably RSI more often than a City service.


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## BLS Systems Limited (Sep 18, 2012)

usalsfyre said:


> Ehhh, perhaps. I also know a lot of very good clinicians who get very nervous about giving a patient in respiratory failure a benzo without being ready to tube them.



Interesting point.  The topic of Narcan has been discussed a fair bit but does anyone carry flumazenil as a benzo antagonist?


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## Doczilla (Sep 18, 2012)

I havent seen or heard about it yet in EMS, and its even used sparingly in the ER. Reversing acute benzo OD is more dangerous than acute opiate OD. 

That being said, you have a decent amount of play with benzos if you titrate carefully. 

Theres always a .25-.5mg/kg hit of ketamine, too. Just watch for hypertension. Chase with 2mg or so of versed too.


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## medicdan (Sep 18, 2012)

Would anyone have considered NTI as opposed to ETI in this case? For whatever reason, the provider elected away from CPAP, but wanted a secured airway. For a patient who is breathing spontaneously, doesn't this seems more prudent than MAI/RSI?


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## usalsfyre (Sep 18, 2012)

emt.dan said:


> Would anyone have considered NTI as opposed to ETI in this case? For whatever reason, the provider elected away from CPAP, but wanted a secured airway. For a patient who is breathing spontaneously, doesn't this seems more prudent than MAI/RSI?



The nares are really a poor place to put an endotracheal tube down if you can avoid it, it will have to be converted to the oral route later on anyway. If the patient was a poor candidate for a semi-elective intubation, sure. Otherwise I'd go the RSI route. 

Performed properly, RSI ( with a full slate of drugs, not the "facilitated" crap) is actually a safe and effective procedure. The problem is so few programs have the training time and oversight to do it properly.


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## DrParasite (Sep 18, 2012)

RSI was not done; just a sedative and pain killer (no paralytic), at least that's what I recall.

Resp rate was around 50 (i think, it has been a couple days since the call).  IDK if that changes anything.  

I do think he was beyond coaching, esp with the language barrier.


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## Melclin (Sep 19, 2012)

Doczilla said:


> Theres always a .25-.5mg/kg hit of ketamine, too.



Ahh beat me too it. 

DSI anyone?


I'm behind sitting the guy up post tube. Better alveolar recruitment. 

Can we get some closure on this OPA issue? Whats the go with that?


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## Akulahawk (Sep 19, 2012)

usalsfyre said:


> I might have tried a brief CPAP trial with some coaching. That said, anxiety, agitation and claustrophobia are suspicious for respiratory failure and enough to buy a tube. Without being there I'm not gonna second guess the guy.





fast65 said:


> I forgot about the language barrier, I suppose that is a bit more suspect for respiratory failure. However, I still think a trial of CPAP was warranted before pulling the trigger on intubation. I will admit though, that I probably shouldn't have said this patient was mismanaged, I let the initial description of the medics jade my opinion a bit.


Trial of CPAP sounds perfectly reasonable... however, if the patient is at the point of ripping stuff off... I think I'd seriously consider going straight to ETI too. I'd have to be there to see situation myself though. Given the local constraints out here, I'd have to go to a conscious ETI attempt though, and nobody would be all that happy about having to do _that._ That being said, if the patient tolerates the procedure fairly well, they'd really be bad off as they'd not even fight because they're too concerned with breathing. 

About the only thing I can see with using the OPA on that conscious patient is determining how much he'd tolerate something being put in his mouth... but that might just freak the patient out _more_ and put him further behind. 

Lasix, I'd not have given it until later. It just takes too long for that stuff to take effect. NTG/nitroprusside, well that I agree with.


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## shfd739 (Sep 19, 2012)

I wouldve done a trial of cpap and skipped the lasix. 

I had a patient 2 weeks ago with severe copd exacerbation. Unable to speak and was pulling off the NRB. I was able to place the cpap and after 10mins he was talking and carrying on a conversation with us.


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## Eli (Sep 23, 2012)

This is my first visit to EMTLIFE. And this is the first thread I've really read.
My little back-story... spent years working in an urban area on nights. Treated >100 CHF patients every year. My goal when I started there was to be as good as some of the folks I worked around. I never dreamed I figure stuff out that they hadn't. But I did.

In every service I have worked for or been around, respiratory failure is the ONE area where we can make a difference in short AND long term mortality. It is also the one area EVERY service fails in! Mortality of these patient's is around 6%. More in urban areas, less in affluent populations. My experience with these folks was in the days before CPAP. My plan was simple but effective. My mortality to ICU was < 1 %. None of the patients that I was able to follow up on after admission passed away. But my ability to follow up after the ED was too inconsistent to be a reliable measure. My plan then was calm the patient, AIRWAY, calm the patient, BREATHING, calm the patient, CIRCUALTION, calm the patient.... I always got the nitro on board early. I like a sublingual dose followed by 1-2 inches of paste. I gave the nitro and lasix a chance to work before I EVER considered moving the patient. A CHF patient will always get worse to some degree in the process of moving to the ambulance. Often significantly worse! Screw all the academic criteria they teach us about when to start bagging. You bag them when there's a detiorated LOC or you think they're looking too tired to breath.

Since I left the hood I work in a rural area. I don't see that many patients. And the CHF patient's I see are not nearly as "brittle". Race and economics play a huge factor in these patients. Black people just get the short end of the stick in all areas of cardiovascular issues.

I simply haven't had enough experience with CPAP to have an opinion on it. If it comes down to scoop and run with sirens screaming in the background then yea, CPAP does yield better results. But the results I see with CPAP are about the same as what I got in the 90's without. The main difference I see is that most of my patients were in much better shape by the time I got to the ED than many I've seen hours after arrival at the ED with CPAP. I suspect that has to have some effect on mortality but that's just an educated guess on my part.

With this patient, it would be very hard to coach and comfort him if the language barrier was too severe. There are generally three areas that will adversely affect our ability to successfully manage these patients with just meds. Inability to calm the patient (too anxious, language barrier...), inability to calm the crowd (family, fire, your partner), or inability to give the meds (unsuccessful IV). I found I could manage any one of those areas. But if I encountered two areas of problems that was too much and it was time to switch to a load and go process. Fortunately for me, that was rare. But even without the ability to verbally communicate well it is very conceivable that the EMS team's calm and caring attitude could have been enough to give your patient the patient confidence and reduce his anxiety. Calming him and using nitro would likely have negated the need for CPAP. But at the point you guys got to, I likely would have opted for the CPAP before an ET tube. I don't do RSI; we're just too slow here to have the intubation skills that are needed to go with RSI. Short of RSI, nasal intubation is far more likely to create catastrophic cardiovascular collapse than CPAP is. As to the question of position of the patient after intubation, neither is inappropriate or more likely to be beneficial to the patient.

Okay, I will get off my soapbox now (and this is my soapbox ). Oh one more thing. If these patient’s are hypotensive that changes the game plan. Cardiogenic shock is better managed in the ED than in the patient’s home. Those are load and go patients. Dopamine is good but the ED has additional tools if it doesn’t work. We don’t. Either way, cardiogenic  shock with pulmonary edema has a >90% mortality.


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