CPAP and administeration of oral medications

[chbare]

Respiratory tech or respiratory therapist?

[mobey]

_{With chbare on this topic, I feel nearly lnelligable to answer, but here you go:}

_{The real question you pose is : Should CPAP be removed to administer oral medications?}

_{First we must point out what CPAP is doing in layman's terms.}

_{Continuous positive pressure in the incidece of COPD exacurbation is somewhat "splinting open" the airways by removing the negative pressure phase on inspiration.}

_{The second mechansm is to re-recruit collapsed alveoli, again through positive pressure.}

_{So, the question of removing the CPAP.}

_{As we can see above, CPAP itself is a great temporizing measure to open up the airways, and allow better gas exchange. We must realize thoug that it is only a temporary fix. It can make a very sick patient appear well however if we do not fix the real problem (bronchospasm/secretions), then eventually the patient will decompensate...... or need CPAP for a very long time!}

_{So you need to do a risk/benefit anaysis of your oral meds. By remoing the mask temporarily, some alveoli may re-collapse, the splinting of the airways will cease and the spasm will begin to dominate once again. That said, the speed in which this takes place will be patient dependant. However, if they die of an MI with no treatment, none of it will really matter!}

_{This is the beauty of ALS, you post a clear cut question, and get no answer!!}

_{I will always remove the mask to administer nitro/ASA/Plavix. For the few seconds it takes, even in full pulmonary edema, I have yet to find literature that supports continuous CPAP sans all other treatment.}

Forgot to mention: Nitro drips and CPAP work nicely together fo Pulm edema!

I would do the same in this scenario. A spray or two, then start a drip.

If there was suspicion of a preload dependant blod pressure, I would (and have) forgone the spray, and just start low dose drip.

[BEorP]

Interesting thread. Just a question here for chbare or anyone who knows since we're talking CPAP and COPD. I had been under the impression that in COPD, the CPAP is basically counteracting the loss of radial traction and increased resistance (loss of positive transmural pressure) that has led to the bronchioles collapsing as the equal pressure point moves down below the cartilage supported airways.

Is there something going on with the alveoli specifically as well?

[systemet]

This is the original 1988, ISIS-2 study. Streptokinase (the most widely-used thrombolytic at the time), versus ASA, versus ASA + Streptokinase, versus placebo.

http://www.ncbi.nlm.nih.gov/pubmed/2903874

Either streptokinase alone, or ASA alone, reduced the 5-week mortality by 25%. Given together, there was an even greater reduction.

From this, and later studies, came our current treatment options. As chbare said ASA is absolutely vital.

[J306]

Thanks for all of the responses guys.. Kind of interesting, because I was scoulded by my Pharm teacher for saying I would administer Nitro to a Pulm Edema q 5 minutes while temporarly removing the CPAP mask..

Mobey, I wish that we had Nitro IV on car, during the scenario I said I would give my Nitro either as a nitro patch or through IV infusion to minimize interruptions, but of course it was the program head evaluating me, so of course, he wanted a clear answer as to whether I would take the mask off or not.

After reading a few responses and doing some research, I think I just really have to change my thinking as to what is BEST for the patient, and if that ASA is what stops that ischemia from progressing to infarct, I can't stand here and say it would be the right thing to withold that treatment from the patient.

[Curiosity]

I'm sorry, I meant respiratory therapist. I was exhausted and that was the third time I re wrote that post, I kept loosing it and I was getting angry.

[Sequel]

My concern with administering nitroglycerin to a patient on CPAP would be less about having to remove the mask (because once they have that mask on, they likely won't let you take it off them) so much as lowering their BP too much. In the few times I've used CPAP on a patient they had very drastic drops in their blood pressures. My last patient went from 199 systolic to 116 in 5 minutes. Not that I've ever seen nitro drop BP that much, but with those kinds of rapid changes I'd be cautious about controlling that blood pressure.

[Arctickat]

Mobey, I wish that we had Nitro IV on car, during the scenario I said I would give my Nitro either as a nitro patch or through IV infusion to minimize interruptions, but of course it was the program head evaluating me, so of course, he wanted a clear answer as to whether I would take the mask off or not.

I liked making Duane's life difficult back in the day. I'd have stuck to my guns and said I'd administer nitro IV. There's no reason we can't if it's available...if he wants a response requiring you make the absolute choice whether or not to remove the mask....make him ask a question that forces you to make the choice. Then again, I pissed him off so badly that he ended up trying to kick me out of the program on a trumped up charge anyways so it might not be so wise to become a thorn in his side.

Edit:

Sequel...consider what you're saying regarding the drop in BP and the mechanism of action. Perhaps that reduced BP was the result of a physiological response by the body because it was returning to homeonormal status.

Edited October 30, 2012 by Arctickat

[rallymedik]

Put the pills in a straw..pull hose off CPAP momentary..stick straw in mouth..and down she goes.

Patent pending! Ha!

[jkc]

With a bit of coaching you can maintain CPAP's positive airway pressure during nitro admin:

Go through the nitro admin procedure with the pt before removing the mask. Unstrap it while holding it on the face manually. Remember you don't want the pt inhaling SL nitro, and you want the pt to lift their tongue to the roof of their mouth. So if you can coach the pt to hold their breath for a moment, put their tongue to the roof of their mouth, and then quickly take the mask off and spray, the pt's glottis should remain closed maintaining airway pressure - and airway splinting.

It's not perfect, and you need to be fast and have a compliant pt, but I've had a run of CPAP calls in the past 6 weeks and it seems to work.