CPAP for COPD ?

[philslat]

We have CPAP in our system solely for APE

We cannot use it for exacerbations of copd although we can use it in APE regardless of a history of copd

Have been reading some articles and saw a recent podcast advocating its use for exacerbations of copd

Is it a safe and effective treatment in these cases ?

 

[NPO]

CPAP has been shown to reduce both mortality and intubation rates in COPD patients. It's a very effective treatment. It also helps to deliver bronchodilator medications deeper into the lungs when constricted.

 

[philslat]

Can it cause a pneumothorax in these patients ?

 

[Carlos Danger]

Can it cause a pneumothorax in these patients ?

Potentially.

 

[philslat]

Potentially.

The consensus of opinion is that this is the reason the treatment is contraindicated in exacerbations

Is it a case of the benefits out weighing the risk for those systems that use cpap for these patients ?

 

[photog]

Potentially.

Yes. Though it’s quite rare with 5-7,5 cmH2O pressures.

We tend to use NIV (PEEP 5-7, Psupp 5-8, FiO2 21-100% depending on SpO2 and overall situation) instead, but CPAP is a great backup when NIV is not available.

 

[PotatoMedic]

The consensus of opinion is that this is the reason the treatment is contraindicated in exacerbations

Is it a case of the benefits out weighing the risk for those systems that use cpap for these patients ?

Exacerbation is the perfect time to use CPAP. It can help prevent the need to intubate a copd patient who, as said before, tend to do poorly if intubated. Our only contrindications are:
Physiologic
• Unconscious, Unresponsive, or inability to protect airway.
• Inability to sit up
• Respiratory arrest or agonal respirations (Consider Intubation)
• Persistent nausea/vomiting
• Systolic Blood Pressure less than 90 mmHg
• Inability to obtain a good mask seal
Pathologic
• Suspected Pneumothorax
• Shock associated with cardiac insufficiency
• Penetrating chest trauma
• Facial anomalies / facial trauma
• Has active upper GI bleeding or history of recent gastric surgery

 

[philslat]

Thanks guys

 

[philslat]

A further question

At what point do you resort to cpap in an exacerbation

Do you jump straight in with it or do you use it if patient not responding to standard salbutamol and combivent nebulizer treatments ?

 

[DesertMedic66]

It’s going to depend on what is currently going on with the patient. If the issue just started and/or I am the first one to start treating the patient then CPAP/BiPAP may come further down the line. If the patient has been taking his medications all night long with no relief and looks bad then I am likely to move CPAP/BiPAP higher up on my list of treatments.

 

[ThadeusJ]

CPAP can decrease the work of breathing, hence its use in COPD, asthma and other pathologies not APE. Technically, any positive pressure application has the potential to create a pneumothorax, so you always have to be vigilant. Its interesting that your protocols may not indicate its application, however it will be one of the first things they apply when you transfer care to the hospital.

Most CPAP systems will allow the concurrent application of a neb treatment while CPAP is being applied. You'll have to assess the patient and treat them case by case to determine which (CPAP vs neb) comes first (if at all). As stated above, if the patient has just finished a battery of neb treatments, one could suggest that yours don't have that magic power to affect a difference unless its a difference med, dose or route.

 

[NPO]

A further question

At what point do you resort to cpap in an exacerbation

Do you jump straight in with it or do you use it if patient not responding to standard salbutamol and combivent nebulizer treatments ?

For me, it's always a "you know it when you see it". I know that doesn't really help. It's the sicker ones that are bordering on intubation. A lot of times these patients can tell you if they've ever been on BIPAP or intubated. Ask then, and that will give you some insight to the severity of their disease.

As others have said, my Albuterol isn't better than theirs and a LAMA like atrovent isn't going to get them out of the danger zone.

My last BIPAP patient called us after an hour or so of no improvement. He was on a nonselective beta blocker which is going to reduce the effectiveness of beta 2 agonists like Albuterol, so I went straight for BIPAP.

 

[philslat]

Thanks NPO

Just to clarify BIPAP and CPAP are not the same

Correct ?

 

[NPO]

Thanks NPO

Just to clarify BIPAP and CPAP are not the same

Correct ?

Correct. CPAP is a continuous pressure that you set (usually 5, 7.5 or 10) BIPAP (or, technically bi-level) uses higher pressure on inspiration. This works to reduce the work of breathing.

BIPAP requires a vent, while CPAP can be done with cheap disposable devices.

 

[E tank]

CPAP can decrease the work of breathing, hence its use in COPD, asthma and other pathologies not APE. Technically, any positive pressure application has the potential to create a pneumothorax, so you always have to be vigilant.

Something else to consider than a pneumothorax and more common is the risk for dynamic pulmonary hyperinflation, or breath stacking which can lead to a serious fall in venous return. Lower pressures are less likely to exceed the disease mediated endogenous peep, but its worth keeping in mind if a sudden fall in blood pressures occurs.

 

[medichopeful]

Can it cause a pneumothorax in these patients ?

PPV can cause a pneumothorax in any patient, regardless of underlying condition or whether it is delivered through CPAP, BiPAP, vent, or BVM.

 

[medichopeful]

BIPAP requires a vent, while CPAP can be done with cheap disposable devices.

There are BiPAP machines that are not ventilators, but not really for EMS.

 

[StCEMT]

A further question

At what point do you resort to cpap in an exacerbation

Do you jump straight in with it or do you use it if patient not responding to standard salbutamol and combivent nebulizer treatments ?

Just depends on where they fall on that sliding scale in my head. If the words "well ****" cross my mind right away, CPAP is soon to follow. Especially if they have taken meds with no improvement. If they are closing in on that oh ****, but not there yet, I will often opt to go aggressive with pharm and have CPAP handy on stand by. I have had success with that route many times, especially with patients I am familiar with and how they respond to meds.

 

[Tigger]

It is rare (for me) that these patients have not already maxed out on their home duonebs. That being the case I usually just go right to CPAP with continuous albuterol neb and then determine what other pharm might be useful.

 

[FiremanMike]

My last round of research on this topic revealed that CPAP -MAY- help in COPD exacerbation but the exact physiology behind why it works was still unclear.

What I train our folks here is this;

CPAP may be an intermediate step before intubation in COPD patients, but you need to be ready and willing to move on if it doesn't help (pre-plan you drugs, stage your equipment, and assess the airway difficulty). Anecdotally here - mag sulfate infusions seem to do a better job of turning these folks around than CPAP, and I think the majority of our department has shifted in that direction as the intermediate step before RSI.