Concepts and Use

Presented and adapted by Todd Lang, MD

Improve survivalStabilize patient/relieve symptomsDecrease need for other interventions

By EMSIn EDSpecifically, intubations

Decrease ICU (and transfers out of area)

Reasonably well studied and seems to:Be safe—very rare complications, EMT-B in

MI, WIBe effective—several studies show effects

above both pre- and in-hospitalBoussignac device seems to be best current

option to decrease up front cost for this rare intervention

CPAPNon-invasiveEasily discontinuedEasily adjustedUse by EMT-BMinimal complicationsDoes not require

sedationComfortable

IntubationInvasiveIntubated stays

intubatedRequires highly

trained personnelSignificant

complicationsCan require sedation

or RSIPotential for infection

Conscious patientsTransient interventionIn the “pre-crash” phase of illnessNo risk of complications that RSI bringsNo downstream healthcare implications like

intubation/RSIEasier to do with limited people

Airway pressure maintained at set level throughout inspiration and expiration

Maintains patency of small airways and alveoli

Improves gas exchangeImproves delivery of bronchodilatorsMoves extracellular fluid into vasculatureReduces work of breathing

Adult Respiratory Distress(Age greater than 12)

Routine Medical Assessment

Oxygen2 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

See CPAP Protocol

No

Yes

No

No

Is the Patient wheezing and/or doesthe Patient have a history of Asthma/COPD?

Does the Patient have rales and/or does the Patient have a history of congestive heart

failure (CHF)?

YesAdminister Albuterol / Atrovent by Nebulizer

Contact Medical Control, consider

sublingual NTG ifsystolic BP is >100mmHg,

possible furosemide if long transport

Yes

Contact Medical Control

Asses Patient, record vital signsand pulse ox before applying oxygen

Does the Patient meet two or moreInclusion Criteria?

No

Yes

Does the Patient meet anyExclusion Criteria?

Continue standardRespiratory Distress Protocol

Administer CPAP5 cm H2O of pressure AND

Reassess patient, vital signs, andrespiratory distress scale every 5 min.

Patch to Medical ControlRespiratory Distress Protocol

Patient condition is stableor improving

Continue CPAPReassess patient every

5 minutes

Patient condition is deterioratingDecreasing LOC

Decreasing Pulse Ox

Notify Medical Control

Remove CPAPApply BVM Ventilation

Mask CPAP for EMS

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 CPAPCongestive Heart Failure

COPD / AsthmaPneumonia

Yes

No

Complete Airway Data Form and submit PHC for each patient placed

on CPAP

CHF Pulmonary Edema

Near Drowning Inhalation Exposure

COPD Asthma Pneumonia

Code/cardiac arrestTrauma to faceUnable to get a seal with maskPneumothoraxVomiting/upper GI bleedingPatient intolerance (despite treatment with

midazolam)

Oxygen supply is rapidly depleted at higher pressure rates

Pressure levelMost studies show 5cm H20 sufficientComplication rate goes up with pressure5cm is probably best place to start EMS CPAP

and titrate if needed from there

CPAP is a non-invasive procedure that is easily applied and can be easily discontinued without untoward patient discomfort

Data supports its use in CHF, pulmonary edema, COPD/Asthma, and pneumonia

Data support EMS CPAP use and its safety and benefits to patients

Boussignac CPAP System

Instructions for Use

Select the appropriate size face mask for your patient:

- Child Mask (Size 3) - Small Adult Mask (Size 4) - Medium Adult Mask (Size 5) - Large Adult Mask (Size 6)

Set Oxygen flow to deliver CPAP in cmH2O of water pressure:

- 15 liters = 5cmH2O - 20 liters = 7.5 cmH2O - 25 liters = 10 cmH2O

Attach the head strap to the hook rings on one side of the Boussignac CPAP mask.

Explain to the patient how the Boussignac CPAP will help their breathing.

Gently hold the mask to the patients face insuring a good face/mask seal.

Turn the flow control device to the desired liters/min, generally 15 l/min, to begin the CPAP.

Gradually adjust the flow to achieve the desired level of CPAP.

Move the head strap around the patient’s head. Insure that the round disk on the head strap is located on the crown of the patient’s head. Attach the head strap on the hook rings.

Check around the mask for any leaks.

Adjust the mask and/or head strap accordingly to insure the patient’s comfort.

Monitor patient’s vital signs.

If the patient requires suctioning of the oral cavity, insert French size suction catheter through the open end of the Boussignac CPAP System.

CPAP pressure will not be affected.

Fill the nebulizer with the prescribed medication.

Insert the 22 mm male end of the nebulizer into the face mask.

Insert the 22 male end (white) of Boussignac CPAP into the nebulizer.

Monitor patient’s vital signs.

Connect the funnel end of the nebulizer’s gas delivery tube to a gas source.

Turn on gas source to 6 liters/min. to power the nebulizer.

Maintain O2 flow to Boussignac CPAP System at 15 l/min. (5cmH2O).