CPAP: When To Pull The Trigger

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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. :)
 
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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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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When to pull the trigger in CPAP? Early and often. I regularly use pharmacology in conjunction with it.
 
my former medical director wanted to give CPAP to the BLS providers as well :unsure:
 
DrParasite said:
my former medical director wanted to give CPAP to the BLS providers as well :unsure:
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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.
 
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.
 
I see lots of agencies misunderstand the role of NIPPV in asthma...
 
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 :rolleyes:

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?
 
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.
 
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.



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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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?
 
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?
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What meds are they missing?


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


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Just post it here...
 
exodus said:
Just post it here...
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I was thinking that after I posted, but I was just a little too lazy to say it :P


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