Should we have used PEEP?

[HarryM]

Went to an interesting job yesterday and had an odd SOB case that I had never seen before so just wanted to check if anyone out there had had anything similar and for those that had if their treatment options may have differed.

Elderly gentlemen with severe SOB from acute exacerbation of pulmonary fibrosis for 2-3 hours before calling ambulance. Patient on home O2 via nasal prongs. Arrive and patient is in a lot of distress, appears very SOB and very restless. RR 40, HR 120, BP 150/90, SPO2 78%. Only other medical history is longterm asymptomatic AF. No chest pain. No illness lately. Temp normal. Lungs both clear on auscultation. Nothing abnormal on 3-lead (apart from AF).

Started him on an acute mask @ 5L and this improved SPO2 to 85% but didn't improve SOB or agitation. Moved up to a reservoir mask @ 10L and saw dramatic improvement. RR decreased, SOB virtually disappeared and SPO2 came up to 97%. He became much more relaxed and we took him through to hospital. No issues the whole transport until 2min out of hospital when his RR and SOB increased dramatically even on the reservoir mask. In ED he went straight to resus.

What I was wondering is if he had deteriorated earlier would he have been a candidate for PEEP? We generally only use PEEP on conscious patients if they have pulmonary oedema so would it even help someone with pulmonary fibrosis?

Edit: I just saw the Patient Care area so apologies if this is in wrong area.

Edited August 12, 2012 by HarryM

[Kaisu]

Was this patient intubated in the ER? If he had deteriorated earlier, I think I would have RSI'd and intubated, The first ventilator setting is PEEP, and I don't see contraindications to this. Pulmonary fibrosis is obstructive, and thus fits the criteria for PEEP.

[chbare]

Pulmonary fibrosis is considered restrictive for the most part. Cystic fibrosis; however, has a significant obstructive component. I believe the OP is talking about an un-intubated patient. In this case, the PEEP the OP is talking about is CPAP. There really is no difference between PEEP and CPAP except how one interprets the context in which we use the terminology.

Using CPAP on this patient fits into a grey area. I see no absolute contraindications and certainly a short trial of CPAP is not outside the realm of reason.

[Kaisu]

I should just wait for you to answer first chbare, and then pretend to know what you know... Thank you again.

[Arctickat]

Yeah, this client would be a candidate for CPAP in my care.

[eb1040]

Lungs clear? I would have expected some chronic crackles with the pulmonary fibrosis. Any history of pulmonary hypertension and if so, what meds? What anticoagulant was this person on since he had a history of Atrial Fibrillation? Had anything changed with that? This may have been something other than the pulmonary fibrosis causing the shortness of breath. In that case the CPAP or PEEP probably would not have been of much use. It also would depend upon the device and how much FiO2 can be delivered especially if pulmonary hypertension or pulmonary emboli are to to considered. Also, with this degree of distress it is doubtful many of the prehospital CPAP devices would have made a difference and may have worsened the situation in the set up.

This is also one of those situations where you might have to overcome the fear of giving too much oxygen and go very aggressively. These patients have little to no reserve.

Edited August 12, 2012 by eb1040

[chbare]

I should just wait for you to answer first chbare, and then pretend to know what you know... Thank you again.

No worries, keep posting. We all potentially have something to bring to the discussions here.

[mobey]

For the first time, I am going to disagree with chbare, and accept my disapline for doing so.

I have a real problem allowing people to decompensate in a prehospital setting. We have potentially the most Uncontrolled intubation setting there is in healthcare, and allowing patients to get severely hypercarbic/hypoxic prior to sedating and possibly paralyzing them, really stacks the odds against us.

Perhaps in a constrictive event, or an edema event, where pressure support can make a dramatic difference CPAP would be first line, but in a case like this, early intubation is my first bet. These and traumatic chest injury patients are just not the ones to deploy the CPAP trials, or wait and see treatment regimes.

Ok. Chbare, let me have it!

[chbare]

Why do you disagree exactly? As I stated, pulmonary fibrosis may be a grey zone; however, non-invasive ventilation may improve oxygenation and decrease the need for intubation. NIV has been used to help patients with restrictive lung disease, therefore I would not have an issue with a pre-hospital trial. In this case, the patient improved with initial therapy and did not deteriorate until a couple of minutes prior to ER presentation.

Also, we do not know if the fibrosis was the underlying cause of the patient's distress. As I stated a grey area, but still a consideration.

[HarryM]

Thanks for your replies.

Bit of further info: we couldn't see any evidence of any other cardiac or respiratory related events going on - not to say that there weren't but our assessment didn't pick up any evidence of this. The lungs were clear and from what I have researched pulmonary fibrosis may produce a crackle in the base of the lobes but not always and it can be hard to hear. As for meds, my crew partner was in the back with the patient and I was driving so I don't remember off the top of my head what his meds were. Not sure what happened in ED after we left.

Our PEEP is just a PEEP valve attached to a bag mask, so you put the mask over the pt and ensure a tight seal and they breathe through the mask. If breathing is inadequate then you can assist ventilations. So we don't have any CPAP as such. Basically I'm not sure if PEEP would have been helpful considering pulmonary fibrosis is not an obstructive disease, but just bouncing things around in my head to see if we get something similar in future whether it might be worth a try (if someone deteriorates before getting to hospital).