CPAP over Intubation

[FireMedic65]

Just curious of who out there uses CPAP. More importantly, what is your criteria when choosing to use the CPAP instead of intubation. From what I have experienced, using CPAP helps greatly so you do not have to intubate. Everyone seems to have a different opinion on when to use one or the other.

[fiznat]

To qualify for CPAP where I work, patients must be alert and spontaneously breathing with bilateral rales and a blood pressure over 100 systolic. These patients don't get intubated unless they lose consciousness to the point where they no longer meet the above criteria. We don't have CPAP-capable vents here anyways so once we tube these patients we're pretty much relying on mechanical PEEP which (IMHO) aint so hot.

[VentMedic]

We don't have CPAP-capable vents here anyways so once we tube these patients we're pretty much relying on mechanical PEEP which (IMHO) aint so hot.

Now if you are talking about something like trying to provide PEEP with an ATV, then it would be a far stretch to consider that a "vent" capable of anything other than pushing air into the lungs like an automated BVM.

Mechanical PEEP and CPAP have similiar valving and utilize the same principles. PEEP by ventilator can be by far more effective especially if the ventilator has a greater flow capability than most prehospital CPAP machines. PEEP is the bases for all lung injury and ARDS protocols.

What do you think we used both in transport and in the hospital before the CPAP devices got very portable? We used ventilators. We still use ventiators to provide CPAP as well as BIPAP (tradename for Respironics). And, it is the same knob that provides PEEP.

[fiznat]

Sorry, maybe a bit of a terminology mix up there. What I mean is, we have a really old vent that does not provide PEEP at all. The best we can do for an intubated patient is this little plastic device we attach to the BVM or vent circuit which is supposed to add the PEEP (is that an ATV? I donno). I'm no RT but I don't believe this device is as effective as an actual PEEP-capable vent or CPAP.

Edited March 11, 2009 by fiznat

[VentMedic]

Sorry, maybe a bit of a terminology mix up there. What I mean is, we have a really old vent that does not provide PEEP at all. The best we can do for an intubated patient is this little plastic device we attach to the BVM or vent circuit which is supposed to add the PEEP (is that an ATV? I donno). I'm no RT but I don't believe this device is as effective as an actual PEEP-capable vent or CPAP.

That is an external PEEP valve which is found on even the more sophisticated transport ventilators like the LTV 1000. The newer models are now coming with internal PEEP. It can still provide adequate PEEP if the flow by the machine is adequate. Since ventilators are generally capable of providing more flow it is much more efficient and effective than most prehospital devices which use the same or similar valve .

It is not as effective on a BVM since the flow available is just 15 l/m max but will still offer some PEEP. This can also be seen by some who crank down these valves on the BVM during a code or hemodynamically unstable patient to "get better oxygenation". They may also be cranking down their chances of ROSC due to decreasing venous return capability by increasing the intrathoracic pressure.

ATV: Automatic Transport Ventilator

See the Carevent as an example on spenac's links.

http://www.emtcity.com/index.php?showtopic=14405

Edited March 11, 2009 by VentMedic

[FL_Medic]

We have an adjustable CPAP device. We can adjust the flow and Oxygen (because CPAP uses fiO2). We also use the adjustable PEEP valve. This allows us to use lower PEEP for the chronic lungers (COPD patients). I find an inline nebulizer with the CPAP to treat most conscious patient with spontaneous respirations and dyspnea quite well.

**If you use an adjustable CPAP, consider the amount of O2 that you have on the truck. If you can decrease the flow and O2 percentage (titrated to patient's O2 sat), you may save yourself from drying out all your tanks.**

If it's a COPD patient I let my assessment decide my initial treatment, severe distress (pre-respiratory arrest) patients will get the CPAP right away, moderate may get the updraft first (if they've been puffing on Albuterol I will give them a Duoneb mix first). If they can't control their airway, they get tubed.

If it's a CHF patient (or what I thi nebulized nk is CHF. Rales, HTN, Hx) CPAP immediate for all that are conscious, able to control their airway, and have any level of distress. Nitrates would be my second treatment most of the time. I may administer an inline treatment. I usually avoid the Lasix, and MS. Morphine is showing up as a marker for mortality in CHF patients.

Immediately remove the CPAP if:

-BP dramatically decreases

-Increased ST-Elevation or CP

-CPAP valve not properly opening/closing

-patient's overall condition becomes worse

* Most of this is in our guidelines as I stated. However, we do still have Lasix & MS in our CHF protocol.

Edited March 12, 2009 by FL_Medic

[Dustdevil]

We have an adjustable CPAP device. We can adjust the flow and Oxygen (because CPAP is fiO2).

Can you clarify that for us?

[FL_Medic]

It's called the Whisperflow. Attached is some info.

Are you asking about FiO2 specifically?

Fraction of inspired oxygen. CPAP uses air and O2, that's all I was getting at.

Whisperflow.pdf

Edited March 11, 2009 by FL_Medic

[Dustdevil]

Are you asking about FiO2 specifically?

Fraction of inspired oxygen. CPAP uses air and O2, that's all I was getting at.

I know what FiO2 is. What I don't understand is why you think it is somehow the same thing as CPAP. And the above explanation doesn't really clear it up. Looking over the pdf for the device, I still don't see how "CPAP is fiO2". They are completely different things with no direct relationship to one another.

Edited March 12, 2009 by Dustdevil

[FL_Medic]

CPAP uses FiO2. Obviously CPAP isn't itself FiO2. That wouldn't make sense (nasal cannula is oxygen). I will edit the post for ya.