Pre-Hospital CPAP What the EMS Medical Director should know

Keith Wesley, MD Wisconsin State EMS Medical Director drwesley@charter.net

Objectives
Review the goal & physiology of CPAP Discuss the indications and contraindications for CPAP use Review the literature supporting CPAP use Explore the role of CPAP use by prehospital providers Discuss the methods for implementing pre-hospital CPAP

The Goal of CPAP?

Reduce the need for prehospital intubation!

CPAP vs. Intubation

CPAP Non-invasive Easily discontinued Easily adjusted Use by EMT-B Minimal complications Does not require sedation Comfortable Intubation Invasive Intubated stays intubated Requires highly trained personnel Significant complications Can require sedation or RSI Potential for infection

The Problem
Congestive Heart Failure
Incidence 10 per 1000 patient (over age 65) transports 25% of Medicare Admissions Average LOS is 6.7 days 6.5 million hospital days Those who get intubated have significantly longer LOS 33% get intubated without non-invasive pressure support Intubated patients have 4 times the mortality of nonintubated patients

The Problem
CHF/Pulmonary Edema
Interstitial fluid interferes with gas exchange (ventilation and oxygenation) Increased myocardial workload resulting in higher oxygen demands (many of these patients are suffering ischemic heart disease) Traditional therapies designed to reduce preload and after-load as well as remove interstitial fluid

The Problem
COPD/Asthma
Increased work of breathing Hypercarbic (ventilation issue) Traditional therapies involve brochodilators which require adequate ventilation Higher mortality rate if intubated Difficult to wean once intubated Extremely difficult patient to intubate in the pre-hospital arena usually requires RSI

Physiology of CPAP
Airway pressure maintained at set level throughout inspiration and expiration Maintains patency of small airways and alveoli Improves gas exchange Improves delivery of bronchodilators Moves extracellular fluid into vasculature Reduces work of breathing

Supporting Literature
JAMA December 28, 2005 Noninvasive Ventilation in Acute Cardiogenic Edema, Massip et. al.
Meta-analysis of studies with good to excellent data 45% reduction in mortality 60% reduction in need to intubate

Supporting Literature
Reviews in Cardiovascular Medicine, vol. 3 supl. 4 2002, Role of Noninvasive Ventilation in the Management of Acutely Decompensated Heart Failure Though BLPAP has theoretical advantages over CPAP, there are questions regarding its safety in a setting of CHF. The Key to success in using NIV to treat severe CHF is proper patient selection, close patient monitoring, proper application of the technology, and objective therapeutic goals. When used appropriately, NIV can be a useful adjunct in the treatment of a subset of patients with acute CHF at risk for endotracheal intubation.

Supporting Literature
Brochard (French abstract) Noninvasive ventilation for acute exacerbations of COPD can reduce the need for intubation, LOS in hospital, and mortality rate

BiPAP vs CPAP
European Respiratory Journal, vol. 15 2000 Effects of biphasic positive airway pressure in patients with chronic obstructive lung disease
BiPAP resulted in overall higher intrathoracic pressures reduces myocardial perfusion BiPAP resulted in lower tidal volumes BiPAP resulted in higher WOB

Pre-hospital CPAP
PEC 2000 NAEMSP Abstract, Pre-hospital use of CPAP for presumed pulmonary edema: a preliminary case series, Kosowsky, et. al. 19 patients Mean duration of therapy 15.5 minutes Oxygen sat. rose from 83.3% to 95.4% None were intubated in the field 2 intubated in the ED 5 subsequently intubated in hospital Pre-hospital CPAP is feasible and may avert the need for intubation

UTMB Experience
Dr. Jeffery Miller UT Galveston IRB approval through UTMB 6 hours didactic instruction Recognize CHF trial limited to CHF
Differentiate CHF, COPD, Asthma & Bronchitis 2 hours clinical training

Instruction on assessment most important reason for success

UTMB Experience
Data Summary Sept. 1996 May 1997
Total intubations 22 Hospital stay 14.8 days ICU admission 100%

Data Summary Sept. 1997 May 1998

CPAP 50 Total intubations 8 (15%) CPAP failures 4 (8%) Hospital stay 8 days ICU admission 48%

Wisconsin EMTBasic Experience

Question: Can EMT-Basics apply CPAP as safely as Paramedics? 50 EMT-Basic services 2 hour didactic, 2 hour lab, written and practical test Required data collection Compared to same data collected by ALS services during same period

Wisconsin EMTBasic Experience

Required data collection
Criteria used to apply CPAP Absence of contraindications Q 5 min. vital signs including oxygen sats. Subjective dyspnea score

Because EMTBasics dont diagnose a unique Respiratory Distress protocol used to capture patients

Adult Respiratory Distress Protocol

(Age greater than 12)
Routine Medical Assessment

Oxygen 2 LPM via Nasal Cannula Titrate to maintain Pulse ox of >92% Is Patient a candidate for Mask CPAP? -Respiratory Rate > 25 / min -Retractions or accessory muscle use -Pulse ox < 94% at any time No Is the Patient wheezing and/or does the Patient have a history of Asthma/COPD? No Yes Administer Albuterol / Atrovent by Nebulizer

Yes See Mask CPAP Protocol

Does the Patient have rales and/or does the Patient have a history of congestive heart failure (CHF)?
No Contact Medical Control Consider ALS Intercept and Transport

Yes

If Basic IV Tech: Administer 1 spray sublingual NTG every 5 minutes as long as systolic BP is greater than 100mmHg

Mask CPAP for EMT-Basic

CPAP Inclusion Criteria (2 or more of the following) -Retractions or Accessory muscle use -Respiratory Rate > 25 / minutes -Pulse Ox < 94% at any time CPAP Exclusion Criteria -Unable to follow commands -Apnea -Vomiting or active GI bleed -Major trauma / pneumothorax Conditions Indicated for CPAP Congestive Heart Failure COPD / Asthma Pneumonia Asses Patient, record vital signs and pulse ox before applying oxygen Does the Patient meet two or more Inclusion Criteria? Yes Yes

No

Does the Patient meet any Exclusion Criteria? No Administer CPAP 5 cm H2O of pressure AND

Continue standard BLS Respiratory Distress Protocol

Reassess patient, vital signs, and respiratory distress scale every 5 min. Patient condition is deteriorating Decreasing LOC Decreasing Pulse Ox

Patient condition is stable or improving

Notify Medical Control Consider ALS Intercept and continue BLS Respiratory Distress Protocol

Continue CPAP Reassess patient every 5 minutes

Notify Medical Control

Complete CPAP Data Form and submit to service Medical Director for each patient placed on CPAP

Remove CPAP Apply BVM Ventilation

Wisconsin EMT-Basic Experience

Results (preliminary study completed 11/05)
500 applications of CPAP (114 services) 99% met criteria for CPAP on review of medical director No field intubations by those services with ALS intercepts No significant complications All oxygen sats. improved, dyspnea reduced by average of 50%

Wisconsin EMT Basic Experience

State approved CPAP for EMT-Basic scope of practice 2/06 Questions yet to be answered
What conditions did the patients have? Was it applied too liberally?

Key Point
Services without ALS intercept did just as well as those with it

Eau Claire Fire Experience

Paramedic service July 2003 June 2004 Measured end-tidal CO2, oxygen sats., and subjective dyspnea score COPD/Asthma Continuous nebs CHF Nitro infusion or repeated sprays

Eau Claire Fire Experience

50 applications No field intubations Initial CO2 levels average 62 All patients CO2 levels increased during first 5 minutes CO2 levels increasing more than 10 positively predicted CPAP failure

Indications for CPAP

CHF Pulmonary Edema
Near Drowning Inhalation Exposure

COPD Asthma Pneumonia

Items to Consider
How good is current care for respiratory distress?
Aggressive nitrates for CHF? Aggressive use of bronchodilators? Pre-hospital and hospital intubation rate?

Requires active medical oversight

Airway management is a sentinel event

ALS or BLS or BOTH?

Items to Consider
Equipment
Must be easy to use and portable Adjustable to patients need Easily started and discontinued Provide quantifiable and reliable airway pressures Conservative oxygen utilization Not interfere with administration traditional therapies for underlying condition

Items to Consider
Oxygen concentration
Fixed versus Variable rates
Fixed rates are either 35% or 100% in current models but actual concentration will be less depending on leaks and minute ventilation Variable rate increases chance of inadequate oxygen supply

Pressure level
Most studies show 5cm H20 sufficient Complication rate goes up with pressure

Summary
CPAP is a non-invasive procedure that is easily applied and can be easily discontinued without untoward patient discomfort CPAP is an established therapeutic modality Data supports its use in CHF, pulmonary edema, COPD/Asthma, and pneumonia

Questions?