Pre-Hospital Treatment Using The Respironics Whisperflow ... · Charlottesville Albemarle Rescue...

Charlottesville Albemarle Rescue Squad - CPAP

CPAPPre-Hospital Treatment

Using TheRespironics Whisperflow CPAP

Device

CPAP – What Is It?

•C ontinuous

•P ositive

•A irway

•P ressure

Anatomy Review

Anatomy Review• Alveoli

Anatomy Review• Chest Wall

Physiology Review• Normal Respiration

Physiology Review• Ventilation - The mechanical

exchange of air between the lungs and the atmosphere – Pulmonary ventilation refers to the total

exchange of gas. – Alveolar ventilation refers only to the

effective ventilation within the alveoli.

Physiology Review• Respiration - the exchange of oxygen

and carbon dioxide between the atmosphere and the body cells– Occurs at the alveolar level

Physiology Review• Diffusion - the movement of gas from

an area of higher concentration to an area of lower concentration– This is how respiration occurs

• Must have:– Functional alveoli and capillary walls– An interstitial space between the alveoli and

capillary wall that is not enlarged or filled with fluid

Physiology Review• Pulmonary Perfusion - the process of

circulating blood through the pulmonary capillary bed– Must have:

• A properly functioning heart (pump)• Proper vascular “size” (tank)• Adequate blood volume / hemoglobin (fluid)

Using CPAP For Respiratory Emergencies

What Can We Use CPAP

•Asthma•COPD•CHF•Pneumonia

Asthma• A chronic inflammation disorder in the

airways• Acute episodes “triggered” by

something– Causes release of histamine, leukotrienes

• Bronchial smooth muscle constriction• Bronchial plugging from mucus secretion• Inflammation changes

Asthma (cont)

• Leads to increased resistance to airflow!

• Leading to hypoxemia and CO2 retention

• Leading to hyperventilation• Leading to…respiratory fatigue

Asthma Assessment/Presentation

• Tripod Position• Wheezing

– A silent chest is an ominous sound!– Flow rates are too low to generate breath

sounds• Inability to speak• Pulse > 130• Respirations >30

Asthma - Differential Diagnosis

• Consider other causes“All that wheezes is not asthma”

– Pneumonia– COPD– Foreign body aspiration– Heart failure– Pneumothorax– Pulmonary embolism– Toxic inhalation

COPD• Chronic Obstructive Pulmonary

Disease– Chronic Bronchitis– Emphysema

Bronchitis• Inflammation of the bronchioles with

large amounts of sputum present• Mucus obstructions

– Leads to gas trapping– Leads to hyper-inflation– Leads to permanent damage

• SOB because of mucus in alveoli

Bronchitis Assessment/Presentation

• History of respiratory infection• Productive cough

– Large quantity of sputum • SOB• Cyanosis

Bronchitis Assessment/Presentation

Mucus Mucus

Air comes in, but can’t get out!

Bronchitis – “Blue Bloater”• A productive

cough 3 months of the year for 2 consecutive years

Emphysema• Chronic disease• Result of destruction of the alveolar

walls– Cigarette smoking– Exposure to “unfriendly” environment

Emphysema – Assessment/Presentation

• Skinny!• SOB all the time • SOB worsens with any activity• Barrel chest• Long expiratory phase – Pursed lip• Pink in color (polycythemia)

Emphysema – “Pink Puffer”

Pneumonia• Infection of the lung (in the alveoli)• Bacteria or virus invade the lung and

multiply• Body sends WBC to fight infection• Causes “consolidation” in alveoli

Pneumonia – Assessment/Presentation

• Patient looks “ill”• History of fever• Productive cough with yellow/tan/green• Localized wheezing / rhonchi in affected

lobe, breath sounds may be diminished

Pneumonia

Congestive Heart Failure (CHF)

• Left ventricle unable to clear• Leads to increased pressure in left atria• Leads to increased pulmonary

pressures• Fluid collects in lungs

CHF – Assessment/Presentation• Respiratory Distress• Orthopnea

– Must sit or stand to breath comfortably• Spasmodic coughing (pink frothy sputum)• Paroxysmal Nocturnal Dyspnea• Severe Apprehension, Confusion, “Smothering

Feeling”• Cyanosis • Diaphoretic• Crackles • Wheezing?• JVD

CHF – Assessment/Presentation

• Vitals:– Sympathetic NS discharge

• Increased blood pressure early• Decreased BP later as patient tires

– Tachycardia– Increased respiratory rate early (40’s)– Decreased respiratory rate as patient tires

So How Do We Treat Them?...

•The same way we always have. Now we just have a new tool.

Continuous Positive Airway Pressure

• Respironics Whisperflow

Circuit Components• These

components come prepackaged together

• Located inside the flap of the CARS Advanced Airway Kit

CPAP Valves• Valves control

pressure setting• Comes

preassembled with a 7.5 cmH20 valve

• Valves use precision springs

CPAP Generator

How It Works - Mechanically• Venturi Effect – Can generate large

flows (140 L/min) with relatively little oxygen usage– Mixes large quantities of ambient air with

a little supplemental oxygen• FiO2 ~30%

How It Works - Physiologically• Creates a positive end expiratory

pressure (PEEP) of our choosing.

How It Works - Physiologically• It changes the

partial pressure of oxygen in the blood

• Deoxygenated blood has a lower partial pressure of oxygen than alveolar air so oxygen transfers from the air into the blood.

How It Works - Physiologically• 7.5cm H2O CPAP increases the partial

pressure of the alveolar air by approximately 1%.

• This increase in partial pressure ‘forces’ more oxygen into the blood.

• Even this comparatively small change is enough to make a clinical difference

GOALS of CPAP• Change pressure gradient to force more

oxygen into the blood• Maintain positive pressure in the lungs to

force fluid from the lungs• “Splint” alveoli open to prevent collapse

– Greater surface area = improved gas exchange

Oxygen Consumption

Indications• Any patient who is in severe respiratory

distress with signs and symptoms consistent with asthma, COPD, pulmonary edema, CHF, or pneumonia and who:– Is awake and able to follow commands– Is over 12 years old and is able to fit the CPAP

mask to face– Has the ability to maintain an open airway

• AND exhibits two or more of the following:– Has a spontaneous RR >25 breaths per minute– Has SPO2 <94% at any time– Uses accessory muscles during respiration

Contraindications• Contraindications:

– Any patient suspected of having a pneumothorax or has suffered trauma to the chest

– Any patient with a tracheostomy– Any patient who is actively vomiting or

has upper GI bleeding– Any patient with facial trauma or an

inability to gain a good seal when attaching mask to face

Application Procedure

Procedure1. Explain procedure to

patient• Far better success with

explanation and coaching2. Select the proper size face

mask for the patient.• The circuit comes

pre-packaged with a large mask.

• The medium mask has a sizing tool on the bag

Procedure (continued)

3. Attach the corrugated tube from the circuit to the port on the end of the CPAP generator.

4. Attach the oxygen hose to the CPAP generator.

5. Attach the bacteria filter to the port on the side of the CPAP generator.

6. Attach the oxygen hose to a source.

• Any oxygen port in the back of the ambulance

• The green dongle on the regulator in the oxygen caddy

7. Apply the mask to the patient’s face.

8. Pull the straps around the patient’s head and secure to the bottom of the mask.

9. Adjust mask position and strap tightness to achieve a seal with minimal air leakage.

10. Secure the CPAP generator to the patient’s arm.

Cautions• Watch for gastric distension

– = Vomiting• Watch for hypotension

– Due to preload/afterload changes• Watch for a tension pneumothorax

– Especially in emphysema patients

Things To Consider

• CPAP CAN be used on DNR patients• The mask can make them

claustrophobic…even though they need it. TALK TO THEM! COACH THEM!

• If you need a higher FiO2, use blow-by oxygen around the bacteria filter

Parts ‘n Pieces

It’s All In

Parts ‘n Pieces

CPAP KitCPAP KitMedium MaskMedium MaskCPAP Circuit CPAP Circuit

Parts ‘n Pieces

CPAP Circuit BagCPAP Circuit Bag

Parts ‘n Pieces

Where Do I Plug It In?

Step 1: Assemble & Plug In

Step 2: Explain The Procedure!

Step 3: Apply To FaceGive The Patient A Chance To AdjustGive The Patient A Chance To Adjust

Step 4: Secure Straps To Mask

Step 5: Pull Straps Until Snug FitHold The Mask Until Both Sides Are TightHold The Mask Until Both Sides Are Tight

Step 6: Secure The Straps It’s Velcro…Just Push!It’s Velcro…Just Push!

Step 7: Secure CPAP To Arm

Secure To ArmSecure To Arm

Step 8: Evaluate

That’s Great…But What If The Patient Needs A Neb?

What About An Inline Neb?

The Only Non-Standard PartThe Only Non-Standard Part

It’s On The Top Flap

Make Sure It’s Level

Questions?

Pre-Hospital Treatment Using The Respironics Whisperflow ... · Charlottesville Albemarle Rescue...

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