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Prehospital Treatment of Dyspnea with CPAP
Mark Marchetta, BS, RN, NREMT-P
Director, EMS EducationAultman Health Foundation
Canton, Ohio
What is CPAP
CONTINUOUS
POSITIVE
AIRWAY
PRESSURE
Review of Respiratory Emergencies
Respiratory System Anatomy and Physiology
Respiratory Medical Terminology
Respiratory Emergencies / Pathophysiology
Normal Process
Chest Wall
VentilationVentilation refers to the process of air movement in and out of the lungs
The following must be intact for ventilation to occur:Functional diaphragm and intercostal
musclesA patent upper airwayAlveoli that are functional
Diffusion
Diffusion – the movement of gas from an area of higher concentration to an area of lower concentration In the respiratory cycle this refers to the
movement of oxygen and carbon dioxide
Diffusion
In order for diffusion to occur, the following must be intact:Alveoli and capillary walls are functional Interstitial space between the alveoli and
capillary wall that are not enlarged or filled with fluid
Perfusion
Refers to the process of circulating blood through the pulmonary capillary bedIn order for perfusion to occur, the following must be intact:A properly functioning heart (pump) Proper vascular “size”Adequate blood volume / hemoglobin
Respiratory Emergencies
Asthma – Bronchitis – Emphysema
Pneumonia – CHF / Pulmonary Edema
Asthma
A chronic inflammation disorder in the airways
Acute episodes “triggered” by somethingcauses release of histamine, leukotrienes
causes obstruction of airflow
Pathophysiology
Bronchial smooth muscle constriction
Bronchial plugging from mucus secretion
Inflammation changes
Pathophysiology
Increased resistance to airflow!Hypoxemia and carbon dioxide retention
Stimulates hyperventilationLeads to…respiratory fatigue
AssessmentTripod 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
Differential Diagnosis
“All that wheezes is not asthma”PneumoniaCOPDForeign body aspirationHeart failurePneumothoraxPulmonary embolismToxic inhalation
COPD
Bronchitis
Can be chronic or acute
Inflammation of the bronchioles with large amounts of sputum present
SOB because of mucus in alveoli
Signs and Symptoms
History of resp. infection
Productive cough of large quantity of sputum
SOB
Cyanosis
Mucus Mucus
Inspiration – Air Can get in…
Expiration – Air Can’t get out…
The Mucus Obstruction
Leads to trapping of air
Hyperinflation occurs permanent damage
Is the reason chronic bronchitis is classified at COPD
“Blue Bloater”
Diagnosed by several findings including a productive cough 3 months of the year for 2 consecutive years
Emphysema
Chronic disease
Result of destruction of the alveolar wallscigarette smokingexposure to “unfriendly” environment
Signs and Symptoms
Skinny!
SOB all the time
SOB worsens with any activity
Barrel chest
Long expiratory phase – Pursed lip
Pink in color (polycythemia)
“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
Patient looks “ill”
History of fever
Productive cough with yellow tan green
Localized wheezing / rhonchi in affected lobe, breath sounds may be diminished
Pneumonia Assessment
ELDERLY
Altered mental status / confusionmay be only symptom
Fever
Cough
Pneumonia Management
Supportive
Bronchodilators may provide some symptomatic relief if bronchospasm is present
“Heart Failure”
Pathophysiology
Left ventricle cannot effectively pump forward
Left atrial pressure rises
Back pressure of fluid into pulmonary circulation
Signs and Symptoms
Respiratory DistressOrthopnea (must sit or stand to breath
comfortably)Spasmodic coughing (pink frothy sputum)Paroxysmal Nocturnal Dyspnea
Severe Apprehension, Confusion, “Smothering Feeling”Due to hypoxia
Signs and Symptoms
Cyanosis – due to poor exchange of O2 at alveoli level
Diaphoretic
Pulmonary CongestionCrackles Wheezing??
JVD
Signs and Symptoms
Vital SignsSympathetic NS discharge Blood pressure early BP later as pt. tires… bad sign!TachycardiaResp rate early (40’s) resp rate as pt. tires
Signs and Symptoms
Chest Pain Incident may have started with chest pain
(AMI)May not C/O chest pain because too busy
working to breath
Management Goals
Improve oxygenation
venous return to the heart
myocardial oxygen demand
Assessment
IF YOU CAN’T TELL WHETHER A PATIENT IS MOVING AIR ADEQUATELY, THEY AREN’T THE NEED TO INTUBATE IS NOT THE SAME AS THE NEED TO VENTILATE!IF YOU THINK ABOUT GIVING O2, GIVE IT!
Continuous Positive Airway Pressure
Measured in cmH2O Pressure
CHF
Benefits/Advantages of CPAP
CPAP reduces work of breathing by keeping the “wet” alveoli open
If the alveoli are open at the end of expiration, energy is not consumed on the next inhalation
Work of breathing is reduced relieving respiratory muscle fatigue
Benefits/Advantages of CPAP
A higher alveoli pressure will result in a stoppage of fluid movement into the alveoli
Increase in airway pressure results in improved gas exchange
What about the Asthma Patient?
Asthma
CPAP will facilitate the delivery of oxygen and medication
Albuterol through the CPAP mask
What About Patients With Bronchitis and Pneumonia?
Bronchitis / Pneumonia
CPAP will facilitate the delivery of oxygen and/or medication
Albuterol through the CPAP mask if indicated
What about the Emphysema Patient?
Important Point
Emphysema patients do not respond predictably to CPAP
As a general rule…
The larger the “barrel chest” and the more pronounced the accessory muscles, the more caution we should use with CPAP
CPAP Protocol Review
CPAP Study Results
Skills Lab
It is recommended that this lecture is followed by a skills lab to demonstrate CPAP use.
The vendor who sells the CPAP product can provide the demonstration.