CPAP vs BiPAP

NPO

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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.
 

NPO

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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.
 

truetiger

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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.
 

NPO

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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.
 

truetiger

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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?
 

TXmed

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@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.
 

Brandon O

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

DrParasite

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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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Remi

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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.
 

Brandon O

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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...
 

Peak

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

Brandon O

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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.)
 

Remi

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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.
 

Brandon O

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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.
 

Peak

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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.
 

Remi

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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.
 

NPO

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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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