Should we have used PEEP?

[chbare]

Going off topic a bit but you can rig a bag mask, PEEP valve and nasal cannula to provide CPAP. Simply attach the PEEP valve to the bag valve mask and attach to at least 15 LPM of Oxygen. Then, place nasal cannula on the patient running at 15 LPM. This will provide both flow and a constant pressure (CPAP). If anything, you can use it as a pre-oxygenation method prior to intubation.

This is how it's done:

http://emcrit.org/misc/bvm-preoxygenation-and-reoxygenation/

[eb1040]

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).

Is this a Jackson Rees bag or a self inflating one? If it is a self inflating bag I doubt if any alert patient who has a RR of 40 is going to allow you to hold a mask to his face firm enough to make a seal.

CPAP is best done with Continuous flow for a continuous positve pressure in the airway.

The fact that the lungs were clear is a little concerning which gives rise to several other differential diagnoses as I mentioned 2 earlier. Not knowing the medications also does not give us the necessary information. There are some situations where high FiO2 oxygen will be the treatment until intubation can be achieved. With intubation being considered, the high FiO2 would be an appropriate choice unless your bag was a Jackson Rees and not a self inflating where you could provide continuous flow with a high FiO2 for intubation. Some CPAP devices also allow for a high FiO2 and can be used with the intubation pre oxygenation process as can a high flow nasal cannula.

I don't know what ventilator you have at your access but there are a few available that can also provide pressure support which is what Mobey mentioned in his post. That could help but depending on the ventilator used for noninvasive, asynchrony could occur tiring the patient more.

If using a ventilator, a self inflating bag or a good prehospital CPAP device, PEEP would be helpful in some situations with pulmonary fibrosis such as with atelectasis and PNA

[Kaisu]

Going off topic a bit but you can rig a bag mask, PEEP valve and nasal cannula to provide CPAP. Simply attach the PEEP valve to the bag valve mask and attach to at least 15 LPM of Oxygen. Then, place nasal cannula on the patient running at 15 LPM. This will provide both flow and a constant pressure (CPAP). If anything, you can use it as a pre-oxygenation method prior to intubation.

This is how it's done:

http://emcrit.org/mi...-reoxygenation/

This is awesome. If I ever run with a service again that doesn't carry CPAP, I will just grab a PEEP valve from somewhere and know that I can care for the patient that needs it. I think I have found one item to carry in my alternate lifestyle bag besides my cigarettes and phone.

[Bernhard]

Someone (chbare?) recently mentioned a study here about making a working CPAP system out of a continous flow nasal oxygen canule and a PEEP valve attached to a bag valve mask. This simply adds the "C" to the PAP and seemed to work pretty good when you have no dedicated CPAP equipment. Never tried this yet, though (since we have the equipment).

EDIT: oh, was already mentioned. Sorry, somehow I didn't read til the end of the thread...ignore the above.

Edited August 16, 2012 by Bernhard

[FF_EMT7]

I think CPAP is definitely worth a trial, perhaps PEEP in your context. With such a disease process you are always open to issues, however I think that the use of CPAP would be worth the risk. I would definitely hold off on RSI until I have tried a less invasive route. Especially with the patient being elderly, we all know the risk of the patient never coming off the vent. I think we are all guilty of pulling the trigger on RSI a bit faster than we should in some cases, especially the elderly.