CPAP over Intubation

[VentMedic]

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.

I am going to suggest you review Venturi, Bernoulli and work of breathing a little. These will give you an understanding of the relationship of flow and FiO2.

If you decrease flow you can greatly increase work of breathing. If your neb is running at more flow than the patient has the ability to exhale agaiinst, you increase the work of breathing. Or, perhaps the neb inline with the extra flow is the only thing that is keeping them from crashing if you are more concerned about your tanks, which you should carry enough to run a CPAP machine at it fullest from the most distant point of your area. If you can't do something to all the way, don't bother doing it half-arsed.

I also hope you only use the CPAP on spontaneously breathing patients.

Here's the link to Respironics' learning center so you can review the WhisperFlow. It is free and the sign on easy.

http://elearning.respironics.com/index_f.asp

[FL_Medic]

That is correct and why I stated that you titrate the flow and O2. You may also improve the patient's comfort with a decreased flow rate. I am not stating that ou should decrease the flow so much that you are defeating the purpose.

The worry isn't about empty bottles, but if you work in a system as busy as mine you may be able to improve your turn around, and respond to a call that you may be closer to. With the device we use, I have had no problem decreasing the flow and O2 while keeping the patient in their improved state.

I'm not sure I understand your rational with regards to the neb Tx. In the ER RTs frequently deliver inline updrafts with CPAP. I use the procedure outlined by our medical guidelines. Not sure if all/any of my patients are benefiting from just the neb at that point, but if I felt it was warranted prior to just trying the neb by itself... I don't care which is fixing them, I'm just happy they're fixed. I mean that with the least amount of ignorant undertone as possible. I am just pleased anytime I can get a chronic lunger in severe distress to the hospital without a tube, and obvious improvement. Judging by your name, I am sure you are aware of just how many people never get off the vent.

Many of the new CPAP devices have implemented these adjustable features and for good reason. I will read your references though, and look for the research I have seen supporting my statement about titration.

Why, after reading my post did you state "I hope you only use CPAP on spontaneously breathing patients". It was a response to the OP.

Edited March 12, 2009 by FL_Medic