EMS-Friendly BiPAP?

[NomadicMedic]

It's not a matter of CPAP compliance, but the physiological differences between obstructive airway issues which would benefit from inspiratory pressure support versus CHF which only really needs increased PEEP.

But in all honesty, is that a concern in a 5 minute transport?

I hate EMSworld as a source, but that piece makes it pretty clear, "the studies reviewed in this article have not shown a clear or consistent advantage to BiPAP over CPAP in clinically significant outcomes such as decreased mortality, need for intubation, ICU admission and length of hospital stay."

 

[FiremanMike]

But in all honesty, is that a concern in a 5 minute transport?

I hate EMSworld as a source, but that piece makes it pretty clear, "the studies reviewed in this article have not shown a clear or consistent advantage to BiPAP over CPAP in clinically significant outcomes such as decreased mortality, need for intubation, ICU admission and length of hospital stay."

Well, that question is one that I honestly can't answer. I feel like it may make a difference and I feel like we (collectively, not you and I) had similar debates at the early points of CPAP coming in to the EMS world..

 

[Carlos Danger]

I don't think there is anything wrong with preferring equipment that is simple to use.

We used to transport people on CPAP and since we didn't carry a stand-alone CPAP device, we had to use our LTV1200. Anyone who has used an LTV for CPAP knows that it isn't the most user-friendly device for that purpose. There is a little bit of jerry-rigging involved and it is hard to keep the machine from alarming. At least it was with the circuits we had.

Anyway, I would have loved to have a CPAP device that was easier

 

[RocketMedic]

I would like an intermediate option for our COPD patients that are refractory to CPAP.

In all honesty? I think that a BVM with a PEEP valve you can connect to your CPAP mask in lieu of the provided BVM mask is going to be the most effective 'BiPap' answer that you are going to get without buying a vent. It's fairly intuitive for any provider to figure out, easy to set and it is very rapid to configure.n One can also wire in an in-line nebulizer pretty easily.

We had the Impact vent for CPAP and BiPap at EMSA and I honestly find the Flowsafe direct-O2 CPAP masks and the Pulmodyne yellow boxes to be more effective, although they are CPAP only. Coaching people onto BiPap in a prehospital setting is possible, but a lot of the vents out there come with a lot of alarms and proprietary tubing that makes actually applying them to anxious, tachypneic patients who need NIPPV quickly difficult. For example, the Impact was challenged when providing BiPap to patients breathing 40ish times a minute because it was nearing the limits of how fast it could cycle and our training was inadequate at best. Knowing now what I know, I'd take the 'ghetto BiPap' BVM and a PEEP valve and an in-line nebulizer kit over that contraption any day.

Here's some videos that demonstrate the concept.

 

[FiremanMike]

Very interesting, nice find!

 

[gamedic87]

At this point it's risk vs reward from a business stand point. Would it be ideal for every truck to have a legitimate transport vent and someone who knows how to use it? Absolutely! But that would also cost a moderately sized service hundreds of thousands and a boatload of training hours. It just doesn't seem feasible to field them on 911 trucks. It would take far too long to see a return on investment, and unless you work for a city/county service that means you're out of a job. Government is the only business that can consistently operate in the red.

 

[RocketMedic]

BVM + a PEEP valve also helps with intubated patients who need PEEP.

 

[ThadeusJ]

Although the BVM + PEEP valve would create the pressure differential, one of the advantages of a CPAP device is the constant flow which decreases the inspiratory work of breathing. The lack of that flow when using the BVM method minimizes the expiratory work of breathing as there is nothing to breathe out against. Because the two flows add up to total work of breathing, the elimination of one over the other is difficult to choose.

 

[VentMonkey]

@ThadeusJ I believe @RocketMedic was simply making reference to placing a PEEP valve on the BVM to ventilate an unconscious, intubated patient.Your reference seems more along the lines of the thread topic with regards to CPAP as an NIV method of use.

The flow you make reference to would at this point (unconscious/ intubated) render said patient more-than-likely ventilator dependent, allowing for passive oxygenation and ventilation of inspiratory, and expiratory flow respectively.

 

[ThadeusJ]

'Tis true, what you say, but I have seen this being used as a substitute to CPAP (but having to create a seal on a non-tubed pt creates more of a hassle than just using a device).

Many years ago, there was the philosophy of "physiologic PEEP" that stated that the epiglottis created 2.5-5 cmH2O PEEP on its own and the act of intubation therefore bypasses and eliminates it. Therefore, it was felt that the act of intubation automatically required PEEP at the bare minimum. I have uncovered a paper from 1984 that questioned this logic and am unsure whether it is still an urban myth or something that has more bona fide research behind it (but I know its still standard practice in the hospitals). Regardless, a PEEP valve (and for gosh sales, please add a filter to the BVM) should be standard issue.

 

[RocketMedic]

I was definitely talking about what @ThadeusJ was. One can even use a CPAP mask to maintain an airtight seal and attach a BVM with a duckbill valve and a PEEP valve to create low cost ghetto bipap.

 

[SpaRTY047]

Forty + years as a registered respiratory therapist and now here at a rural critical access hospital with some thoughts on this very subject:

We RTs put AECOPD patients (or CHF/pulm edema patients) in AcRespInsufficiency on Bilevel machines specifically engineered for a high baseline (called bias) gas flow. This allows us to more easily "capture the patient's WOB." We then adjust IPAP and EPAP and rise time and inspiratory and expiratory time parameters to off load the WOB from the patient's fatigued muscles of respiration over to the "BiPAP" machine.

However these patients must be transferred to the "big city hospital critical care" which means we must attempt to "match settings" on the LTV 1200. All too often the difference in technology induces panic and anxiety in a patient who's settled down nicely over the last 30 - 90 minutes on the non-invasive ventilator in bilevel mode. Simply put, the LTV is engineered to conserve oxygen cylinder contents......this strategy does not allow use of a bias flow. Lack of bias flow results in enough delay in sensing that the patient is switching between exhalation and inspiration (measurable in milliseconds!!!) that the mechanical support lags behind what the patient needs/demands/craves.

So we place these patients on one of the disposable gas driven CPAP devices; a high flow venturi mask; or must sedate and invasively ventilate!!

The market needs to respond to this need....even if it means someone developing a transport bracket onto which a Phillips Brand V60 NIPPV unit can be properly secured; in a fashion similar to what is currently available for the LTV. The Phillips V60 already comes with enough internal battery supply to allow 15-20 minute intra-hospital transports without interrupting therapy. A proper method for securing the unit within the rig would allow the transport team to plug into the DC-AC power inverter for the 20-60 minute transport.

You guys can learn these machines and we are certainly there in the ED to have fine tuned the device and report off to you.

Good luck to both our specialties in meeting this need......it certainly does exist.

 

[VFlutter]

IIRC the Revel has bias flow up to 10 lpm.

 

[SpaRTY047]

Good Point! Yes, I noted that....but their bias flow comes on in NIPPV for leak compensation at mask seal. Devices similar to the V60 (even the older Vision BiPAP) use constant circuit bias flows of 30 - 70 LPM at all times.....and insp limb and exp limb flow sensors are engineered for immediate response to a flow differential caused by patient's insp or exp flow diverting from (insp) or adding to(exp) the flow differential. It's the ability to detect and respond within milliseconds to very small changes in this high bias flow that gives these devices the advantage over the LTV and Revel.

 

[VFlutter]

No doubt that stand alone hospital NIPPVs offer more features and improved tolerability but they are just not realistic for the transport environment due size, portability, and oxygen consumption. Especially in HEMS where space is at a premium and many new aircraft do not have LOx.

Unfortunately for many patients it is either tolerate the Revel/LTV NIPPV or get intubated.

 

[SpaRTY047]

True that - brother

Currently, even on 30 min ground transport.....it appears there's a safety concern with properly securing auxiliary equipment.

That's the basis of my statement that the only alternative until market demands lead to engineering of a smaller unit, seems to be to devise an anchoring system for the V60 (given that ground transport EMS has DC>AC power inverter and H cylinders)

Pts on helos will still fit your second statement.

 

[MunchkinMedic]

I’m not sure what they carry but I know AMR Maricopa carry’s Bipap from personal experience

 

[grumpy1]

Zoll Vent 731

BiPAP and vent

 

[TransportJockey]

Zoll Vent 731

BiPAP and vent

Is that the zoll aev? We are using that on our 911 trucks and must of our crews like it. We are getting the emv plus for our micu transfer truck soon too

 

[grumpy1]

Is that the zoll aev? We are using that on our 911 trucks and must of our crews like it. We are getting the emv plus for our micu transfer truck soon too

Correct. We have had good success with this vent on multiple aircraft with little problem. Its a bit more affordable that the Revel, which is a great machine as well.