Disposable CPAP and Peep

[NomadicMedic]

We are currently using the pulmodyne disposable CPAP at our service. While I've used it with good results, reports from other medics have been mixed. Reports of low SpO2, and patients not receiving relief seem to be the most common, although nobody has been able to truly quantify their experience.

We are currently using a fixed system, with a 30% FiO2 and 10 cm of peep. It's my belief that patients who are extremely fatigued find it very difficult to tolerate 10 cm of peep and should be at a lower setting, 5 or 7.5cm.

We are now trialing a different version, with adjustable peep and a FiO2 titration device.(they call it the O2 trio, it allows an FiO2 of 30, 60 and 90%)

I believe that clinical signs are far more important; is the patient's CO2 at a normal level, is the work of breathing easing… more so than watching an SPO2 number. If the patient seems to be hypoxic, flowing 6 L of oxygen via my capnography nasal cannula quickly brings the SPO2 up, but doesn't burn through my oxygen with the CPAP set at a higher FiO2

I'm curious if anyone else has any thoughts, comments or experiencing using this device.

Sorry for any funny spelling or grammatical errors. I'm doing this on my phone, while on the run…

 

[ThadeusJ]

I think you've got the right attitude in the way you approach your goals. Too many people focus on the SpO2 when using CPAP where the primary outcome would be the ETCO2. Using the Combo nasal cannula/ETCO2 is the best method of monitoring while increasing delivered FiO2. One could also "Tee-In" supplementary oxygen using an adapter or secondary port (if available) if the combo nasal cannula isn't available. Probably the hardest part is quantifying the work of breathing and using the most appropriate charting to document those changes.

 

[CANMAN]

We are currently using the pulmodyne disposable CPAP at our service. While I've used it with good results, reports from other medics have been mixed. Reports of low SpO2, and patients not receiving relief seem to be the most common, although nobody has been able to truly quantify their experience.

We are currently using a fixed system, with a 30% FiO2 and 10 cm of peep. It's my belief that patients who are extremely fatigued find it very difficult to tolerate 10 cm of peep and should be at a lower setting, 5 or 7.5cm.

We are now trialing a different version, with adjustable peep and a FiO2 titration device.(they call it the O2 trio, it allows an FiO2 of 30, 60 and 90%)

I believe that clinical signs are far more important; is the patient's CO2 at a normal level, is the work of breathing easing… more so than watching an SPO2 number. If the patient seems to be hypoxic, flowing 6 L of oxygen via my capnography nasal cannula quickly brings the SPO2 up, but doesn't burn through my oxygen with the CPAP set at a higher FiO2

I'm curious if anyone else has any thoughts, comments or experiencing using this device.

Sorry for any funny spelling or grammatical errors. I'm doing this on my phone, while on the run…

If they are having difficulty tolerating I would try maybe 7 or so but partial closure of the glottis provides a physiologic PEEP of 4 to 5 so your not going to get much benefit starting at 5 in my experience.

I have also read somewhere with the disposable systems the actual "PEEP" can vary at times when measured vs. what the device is actually set at.

My service uses the PortO2Vent which uses a high pressure source of O2 rather then a liter flow source. They are more expensive obviously then disposable but I have had great success with them. Haven't had many patients unable to tolerate and generally see great results with 7 to 10cm of PEEP.

 

[jrm818]

I've always been a bit confused about these disposable cheap systems...especially the ones that hook onto an o2 Christmas tree with a regulator that at best supplies 25lpm. It always seemed like a patient could easily generate a peak inspiratory flow well above what the device could supply.

A couple years ago my service was switching from the complicated whisper flow system to a cheapie disposable boussignac system and I did some looking.

If I'm correct your system would potentially have some of the problems listed in this article. Namely that it isn't it always able to supply sufficient inventory peak flow for patients in respiratory distress ( forcing them to fight thr machine and generate large negarive pressures) and that as you increase the C PAP pressure that you intend to give, you actually decrease the devices ability to supply high levels of flow.

here is the article along with a Philips marketing paper that claims WhisperFlo is better... Im sure its biased somehow but The point is just to show that some devices not perform quite as expected. looking at some of those graphs is quite telling.

http://bja.oxfordjournals.org/content/102/6/875.full.pdf+htmlhttp://www.healthcare.philips.com/p...wnloads/452296256461-EMS_CPAP_FINAL 10_09.pdf

 

[NomadicMedic]

My service formerly used the PortO2Vent, and recently switched to the Pulmodyne system. Unlike other disposable CPAP solutions, this system uses the high-pressure port to deliver a total of 140 L per minute, using a mix of entrained air and o2. I used it again a few days ago, and had great success with a patient who might have otherwise been intubated. I truly believe that it's a learning curve, especially moving from the PortO2Vent.

I'm curious about agencies that have had specific issues with disposable CPAP. Any best practices that have been identified and implemented are certainly helpful.

 

[ThadeusJ]

Some devices are better than others and you have to weigh the features with the benefits of any device. Of course you have to take studies and white papers with a grain of salt.

Regarding the use of a low flow oxygen nipple to supply, these devices use venturis draw in room air to make up the inspiratory flow. Exhaling against that flow creates the pressure which provides the increased pressure cycling in the system. Different systems will use venturis of different effectiveness and some have adjustable venturis where you can adjust the settings a bit . If the venturi provides adequate inspiratory flow through the respiratory cycle, your pressures will be more accurate.

If the total inspiratory flow is not sufficient, then the patient may have an increased work of breathing trying to make up the remainder of the breath. Some products have anti-suffocation valves while others make the patient breath through the system. If its a significant difference, the inspiratory pressure will drop out and you lose your positive pressure.

The PortO2vent is designed in a similar way as a SCBA or SCUBA where the majority of the breath is 100% from the cylinder. Some room air may enter the system and a safety valve will crack open in extreme circumstances or in the event of cylinder depletion. Its a great machine but acts more like a ventilator than a disposable device.

Recent developments in disposable devices have shown several approaches to delivering CPAP. A lot of it depends on how much money you have, the skill level of the staff and your patient population/location of your service (longer response times versus shorter urban ones). Careful consideration is required to ensure the right device is acquired for your service.

 

[emtdansby]

My company currently uses the FlowSafe 2 EZ disposable CPAP system and I love it. Each system comes complete with mask, peep gauge and an adaptor for in line neb treatments. The straps are very easy to strap on and adjust and the entire system use less O2 than most systems. 8lpm=5 peep, 10lpm=7.5 peep and 12lpm=10 peep. I always say the best way to learn about adjusting and fitting these system is to put it on yourself. I even hooked up to O2 and felt the resistance at 5 peep. This system is the best disposable CPAP I have ever used. Now, our criticize care unit have vents that are capable of CPAP and BiPAP and the FlowSafe mask is compatible with our vent tubing. You can't compare disposable and vent driven, vent driven always wins.

 

[Handsome Robb]

My service formerly used the PortO2Vent, and recently switched to the Pulmodyne system. Unlike other disposable CPAP solutions, this system uses the high-pressure port to deliver a total of 140 L per minute, using a mix of entrained air and o2. I used it again a few days ago, and had great success with a patient who might have otherwise been intubated. I truly believe that it's a learning curve, especially moving from the PortO2Vent.

I'm curious about agencies that have had specific issues with disposable CPAP. Any best practices that have been identified and implemented are certainly helpful.

I don't have any real complaints about the Pulmadyne system minus the noise but someone on here gave me a pointer that was a night and day distance.

I believe it supplies about a 40-45% FiO2 between the flow from the tank and recruited air from the room. One thing though if you obstruct the room air vent get ready for that thing to come off their face fast by their doing. Had a coresponder throw a blanket over it on the back of the gurney, innocent mistake. Almost ended very badly. I'm a lot more careful about how I setup my circuit now.

 

[socalmedic]

we used to have the Pulmodyne unit, and before that the bousignaick (SP?) but we have switched to the FlowSafe and love it.

the bousignick had no control, it was all guess work as to how much PEEP the person was actually getting. but it was very simple and took up no space.

the pulmodyne o2-rescue didnt last long. it is BIG and we had no room for a both sizes in the bag, it uses alot of oxygen and I mean A LOT. and worst of all it is loud, whenever we used it I though we needed to get clearance of take off and then let our hospital know when we were on final approach.

the FlowSafe is the best we have used, but its straps could use some work. there is a manometer on the mask and I typically get 7-10cmH2o at 10-15LPM at sea level, some patients need slightly more power to keep the pressure up on inspiration.

 

[RocketMedic]

Yall need an Impact AEV. Accept no substitutes, get a vent.