VBEMS training documents indicate the physiological benefits of CPAP are an increase in alveolar pressure, reduced work of breathing and respiratory muscle fatigue, increased intrathoracic pressure and a decreased need for intubations.
To receive CPAP, patients must be 8 years old or older and contraindications include:
- Unable to maintain drive to breathe
- Decreased level of consciousness
- Facial trauma/ burns
- Penetrating neck and chest trauma
- Recent facial surgery
- Patient unable to tolerate mask
- Active vomiting
- Precaution if systolic BP less than 90 mm/Hg
This means the patient must be alert and able to follow commands (cannot be responsive to verbal, pain or unresponsive) and their systolic blood pressure should ideally be 90 or greater. If the patient has a slightly lower blood pressure, it may be acceptable to apply CPAP and closely monitor the blood pressure to ensure it isn’t falling too low. A decent rule of thumb is if you can’t administer nitroglycerin to the patient due to low blood pressure, it may be wise to avoid CPAP.
CPAP can be applied in the congestive heart failure patient as a first line treatment. However, the OMD’s indicate that “Provider shall administer a minimum of 1 SL nitroglycerine prior to application of CPAP for HF.” As your treatment continues, it is acceptable to remove the mask briefly to administer additional nitroglycerine. Remember that Lasix now requires a physician order for all certification levels in these patients.
CPAP should be used in the asthma patient when you are considering intubation. This assumes they meet application criteria and nebulizers are not making any progress. Concurrently, solumedrol and Mag can be administered.
While reviewing CPAP cases for 2017, we noted CPAP was used/attempted 184 times as documented in the Elite procedures. Only three were listed as not successful because the patient would not tolerate, CPAP was removed due to decreasing LOC and CPAP was left in place with decreasing LOC.
There were 12 cases where the patient had a documented significant altered mental status including four cases where the patient was noted to be unresponsive. At least one case specifically mentioned inadequate tidal volume prior to applying CPAP. If the patient is that altered and/or has poor tidal volume, BVM and possibly intubation should be your go to therapy. Remember that CPAP doesn’t ventilate the patient—it only allows the alveoli to remain open for improved gas exchange so they must have an adequate respiratory rate and tidal volume.
When CPAP has been applied, please monitor your patient’s vital signs, ability to breathe, tidal volume and mental status at least every 5 minutes. If you are not seeing improvement or the patient’s condition is worsening, you need to act quickly and CPAP may no longer be appropriate.
For more information, please review:
VBEMS CPAP training material on Moodle (under ALS Release training or CPAP for the AEMT as appropriate) at http://learn.vbems.com/
TEMS protocols (Breathing Difficulty and CPAP reference section) at http://tidewater.vaems.org/regional-protocols/current-tidewater-ems-regional-protocols