CPAP discussion

[mobey]

To fully understand my position please understand this: I transport my patients to a small rural clinic with a few on-call GP's. There is very very little real EBM or even target based medicine go on out here.

Given we are in flu season full force, I have had quite a few of the following patients:

Elderly, Cardiac history, cough for a week or more, febrile, weakness, wheezy/crackly lungs.

Specifically I am talking the critically ill ones here. grey, Sp02 in 70/80's but not hypotensive.

For the most part I diagnose them in pulmonary edema with underlying chest infection.

As of late I have been treating with ventolin, and Nitro and having good results. The problem I am having is as soon as I get to the freaking clinic all treatment stops while the doc's start lasix therapy. There is just not enough time to clear up the edema with Nitro prior to transfer of care.

To be honest I would like to put these people on CPAP, however I have always stayed away from CPAP in suspected pneumonia patients.

Thoughts?

Oh ya: try to resist the temptation to derail this thread into a SIRS/SEPSIS thread at least for the first page.

[JakeEMTP]

I wasn't sure how to respond to your topic, I just didn't know. I did admittedly very little research on this because to be honest, I'm tired. I did find this little blurb which was sort of interesting. Clearly, the jury is still out on the use of CPAP pre-hospital and pneumonia pt.'s. The studies I have found are mostly on ICU patients. As usual, pre-hospital studies are few and far between. I do find it interesting though that in this albeit small study group, ICU stays were shortened and ET tubes were not as necessary.

Pneumonia

The literature regarding the utility of NIV in pneumonia is mixed. One prospective, randomized study compared standard treatment plus NIV delivered through a facemask to standard treatment alone in 56 patients with severe community-acquired pneumonia.⁶⁹ In those patients with pneumonia and COPD, NIV reduced the need for endotracheal intubation and shortened ICU stays. Other studies also suggest that NIV may improve outcomes in some patients with community-acquired pneumonia.^8,28,70,71 NIV has also been well-described in the treatment of respiratory failure due to Pneumocystis carinii.⁷²

However, some data indicate that patients with pneumonia are the ones most likely to fail NIV.⁷³ In one small study that included 16 patients with pneumonia as a primary cause of respiratory distress, NIV failed to prevent the need for intubation.¹¹ Clearly, further research regarding the utility of CPAP or BiPAP in pneumonia is necessary.

Credit for this passage belongs to www.ebmedicine.net

Very much looking forward to CHbare's input.

[chbare]

Unfortunately, the literature is not going to be particularly helpful regarding this issue. I would also be very cautious about giving Lasix to these patients. It's effectiveness for cardiogenic pulmonary oedema is questionable, never mind non-cardiogenic oedema. Often, patients will be hypovolemic and large amounts of secretions in the lungs that relate to an infectious etiology is not necessarily pulmonary oedema. Also, the role of bronchodilators could be questionable if there is no evidence of bronchospasm.

[mobey]

chbare you bring up so many points I just love to debate!

a) I disagree with the use of Lasix in these patients, the science just does not support it.

Love to have the debate about bronchodilators in pulmonary edema with bronchospasm. I am in support, however most of the pratitioners I debate with are not.

However, for this thread, I would like to hear your personal opinion/rationale for or against CPAP in pulmonary edema with underlying chest infection.

I do realize the literature is less than satisfactory, and that is why I have brought it here.

Thx

[Kaisu]

Given that scientific research is not the issue here I personally would not use CPAP in pneumonia UNLESS there is an edemic component. If there is water there, the CPAP can deal with that and perhaps give the patient what they need to deal with the pneumonia. You just can't push puss (nor would you want to) into interstitial space. (The lasix is worse than useless and has been replaced by beta blockers as a first line treatment for pulmonary edema in progressive EDs).

[chbare]

I would not call Lasix useless. It has it's place, but without knowledge of the underlying fluid and electrolyte status, it can lead to problems. We can no longer give it unless we have labs and have documented and assessed the serum os. Unfortunately, the risk of diuresing volume depleted patients in my area was too great for medical direction to ignore. I'm not clear on beta blockers as front line therapy. They certainly have a role in long term management of CHF patient's and are no longer considered deadly for CHF patients and can be considered in acute management, but I see other classes taking a leading role. The use of ACE inhibitors is quite popular in some areas and there is a fair amount of literature out on the role of neurohormonal modification and possible LV improvement associated with ACEI therapy. However, the interpretation of some of these studies is all over the place. This seems be be especially true in Europe, but I must admit some of the studies being cited do have their weaknesses.

[Kaisu]

Once again, my betters are educating me. I should have said Ace Inhibitors, not beta blockers.... and the lasix thing.. I was referring to front line treatments in the ED.

[Bieber]

CPAP for pneumonia patients in imminent respiratory failure is definitely a better alternative than having to tube 'em. Our (yet to be implemented) new protocols include CPAP for everything except patients with a history of asthma.

[Kaisu]

Would you not worry about CPAP drying out mucus secretions? I thought the rational for fluids in pneumonia was to facilitate loosening of these secretions. Would CPAP not be working at cross purposes to this?

[chbare]

Moby, if you mean Lasix for pneumonia, yes it's not helpful and possibly harmful. However, Lasix in general is not useless. If you have bronchospasm, treat it. However, patients with pneumonia don't necessarily have bronchospasm. I do not support arbitrary, needless use of treatment modalities. If you can make a good case for spasm, fine. This is quite possible with physical exam backed up by waveform capnography. I gather you are talking about treating appropriately and not arbitrarily.

Crap, I am not sure I follow your logic? People with pneumonia may need fluids for a variety of reasons. The goal of CPAP is not to dry out secretions; however, I suppose there is a potential concern of that occurring in the field, maybe. In the hospital, we often heat and humidify patients receiving NIV. In fact, there are reports that NIV may help clear retained secretions.