Pre-Hospital CPAP

[CPAPMedicCO]

Anyone using any type of CPAP Device and if so which one. What were the reasons you chose the device and are you using it at the BLS or ALS levels? Thanks.

[JakeEMTP]

We use the Whisperflow manufactured by Respironics. It has a variable flow rate and has performed brilliantly the few times I have had to use it. One of the reasons we chose this device is the ease of which it is put together. It can be done quickly and is virtually idiot-proof as the parts only fit one way. We have the same device as the hospital, so we can replace the parts that are disposable easily. When we call in to the hospital, we notify them that we have a patient on CPAP and the RT is usually waiting for us when we arrive. All in all, it has worked well.

We are all ALS so we use it at that level.

Here is the device we use.

http://whisperflow.respironics.com/

[Ridryder 911]

There are several good CPAP's out there. We field tested several. We found that Emergent PortO2Vent was the best for us. It is easy to use, and one cannot find a better mask. We also found that it uses less oxygen than others, in which in our coverage area is essential.

After close reviews, we have increased our use of CPAP on almost any major respiratory difficulties. This includes of course CHF , but pneumonia, asthma, bronchitis, etc. We have drastically reduced our need to RSI, intubate and ventilator procedures. As well, our ICU admissions are down drastically too.

In my state CPAP has just been approved for Basic EMT's to use in CHF setting.

R/r 911

[p3medic]

We use the same system as Rid, simple and very effective.

[Spock]

We just put the Emergent model in service last month. We went with that model because the region came up with a bunch of money and bought units for every EMS agency in the region. They bought three units for my service so we only had to buy two on our own. I liked the Whisperflow better but I do agree the Emergent is simpler. The City of Pittsburgh bought the disposable Boussniac (spelling?) units. That unit seems to have the highest oxygen consumption but is very simple.

CPAP is an ALS skill in PA but some ER physicians are talking about making it BLS. We have had good results so far and Rid is absolutely correct that CPAP reduces the number of intubations and also decreases the cost of care. We intubate fewer patients in the hospital because of CPAP and BiPAP.

So far the only problem we have had is getting the ER's ready to accept the patient on CPAP. We give them 10 minutes notice but that doesn't seem to be enough for them. We have short transport times so it is a problem still looking for a solution.

Live long and prosper.

Spock

[katbemeEMT-B]

We also have the Emergent on our trucks for pretty much the same reasons as have already been stated. We are an ALS service with medic and emt staffed trucks. We had to attend a training session and prove we could effectively use the unit before they were introduced as part of patient treatment. Our numbers of intubations and RSI have decreased dramatically. The only problem we have is that the hospital doesn't have the same oxygen connection as our trucks so we have to change out the connecting hose once the patient hits the ED. The other problem is the ED nurses haven't been trained competently on CPAP so we have to babysit the patient until RT arrives.

[EMT007]

CPAP was just approved for use (by ALS or BLS) in my county, and my medical director is pushing for us to get it in the coming months. (We are a BLS unit.) Obviously haven't started using it, but its good to hear that CPAP has been having so much success.

[VentMedic]

The success of CPAP in prehospital is still all dependent on the training of the provider.

It is rare now that even I rush to the ER to set up our machine. When prehospital CPAP first went countywide in my area, we had 22 CPAP calls for the ER in 48 hours. Everybody with the complaint of shortness of breath got a field CPAP mask. Only three of those patients actually warranted setting up the ER machine. Two were actually CHF patients.

The calls consisted of a man involved in an MVC with rib fractures and a pneumo and several nursing home patients "gurgling". Three of the nursing home patients ended up intubated due to aspiration. This might have been prevented if someone had suctioned the upper airways prior to placing a mask with high flow gas pushing everything down further in the airways. One patient vomited enroute which of course led to aspiration and required intubation in the ED. There was also the pulmonary fibrosis patient with chronic crackles that came in restrained to keep the mask on. Problem was, the mask was a 15 liter flow with a "PEEP" resistive valve on a patient that required a MV of 25 liters at an inspiratory flow rate of 120 - 160 liters. Tying a patient down and telling them to breathe "slowly" doesn't always work out. This patient got a very high flow aerosol mask, steroids and a lot of ativan to get him over the anxiety of the experience of being restrainted with a tight mask. Later he was able to try one of our Respironics BiPAP machines.

I probably run faster to the ED when I hear the patient is coming from a nursing home.

The skills and assessment have gotten better but the above mentioned calls were from ALS trucks. Of course, with the exception of WhisperFlow and the Emergent- PortO2Vent or CPAP through the LTV vent, many of the CPAP devices are merely cheap masks with a resistive valve. If the patient is tolerating those things, we don't even take the plastic cover off of the ED machine.

CPAP has been around for almost 40 years and is a great tool. But, it's not for everyone and care still must be taken to clear the airway before applying. Not everyone will tolerate the mask especially if they have a high flow demand or moderate to severe air trapping. The better machines do deliver a higher flow rate and provide a more consistent pressure to splint the airways.

The real beauty of CPAP in CHF is it decreases venous return and afterload as well as unloading the respiratory muscles. If LV contractility normal any increase in cardiac output due to decreased afterload will be small due to decreased preload. If LV contractility markedly impaired reduction in afterload will tend to overcome concomitant decrease in venous return and cardiac output will rise. One should be aware of these shifts in the hemodynamics especially in the cardiac patient. These changes may not always be favorable in the face of an MI. CPAP is applied with a great deal of discretion in the hospital setting.

[CBEMT]

Vent,

Sounds like those systems threw the machines on the truck with no training prior to use.

[VentMedic]

They are too excited about their new toy. They are excellent paramedics but sometimes mechanical devices need a little more training about principles instead of the just "use it" mentality. This was also part of the failure behind the Demand (Elder) Valve. The just push here "skill" without the understanding of what exactly happened after that brought the problems, not the device. Sometimes when you make things too easy, the thinking part goes out the window.

We have 4 main EMS systems coming to us, 2 using WhisperFlow, 1 PortO2Vent and 1 with some cheap face mask device with a 15L max flow. They can't understand why we don't switch to what they're using.

For CCT ground and Flight we use the LTV vent for all purpose ventilation.

Right now is the time to be a sales rep for CPAP to fire departments.