For many years, EMT-Bs have been taught how to manually provide positive-pressure ventilation using the BVM, and routinely use this skill during respiratory and cardiac arrest situations. They’ve also been taught to use it for the patient in respiratory distress with inadequate ventilation, including patients suffering from COPD, asthma and heart failure.
But positive-pressure ventilation in this manner is difficult to perform because it requires carefully squeezing the bag, timing the squeeze with the patient’s inhalation and ensuring the squeeze is of the right volume. If the bag is squeezed too forcibly, the patient may gag or vomit. This results not only in respiratory distress but also in airway patency issues.
Nothing is more frightening than seeing a patient struggle to breathe and then suffer respiratory arrest when your only tools are the BVM and a non-visualized airway. When these patients quit breathing, they often continue to have a gag reflex that makes non-visualized airway insertion virtually impossible. CPAP performs the same mechanics as positive-pressure ventilations in a spontaneously breathing patient, but without the accompanying downsides.
Therefore, five years ago, several states began to consider the value of having EMT-Bs use CPAP. The potential disadvantages of manual positive-pressure ventilation, coupled with an increased risk of respiratory arrest in the absence of ALS interventions, tilted the risk-benefit ratio in favor of CPAP use by BLS providers.
Wisconsin was the first state to examine this issue. Officials first developed a training program, and then they began to implement a pilot project involving BLS services in 2005.
The primary question asked at the time was whether patients who received CPAP by BLS personnel would suffer greater complications than those given CPAP by paramedics. After a year of study, officials found no difference, and actually found that BLS use of CPAP helped reduce the need for ALS for these patients.
In several cases during the pilot program, BLS agencies that used CPAP transported patients with COPD without an ALS intercept. This was because, despite being in their scope of practice, many ALS agencies didn’t have CPAP, and the patients had improved to such a degree that an ALS intercept and intervention was no longer needed. This also freed up ALS resources to respond to additional or more critical calls.
The result was that Wisconsin became the first state in the nation to add CPAP to the BLS scope of practice. The pilot project also resulted in widespread adoption of CPAP by Wisconsin ALS services as well.
According to a recent survey of the National Association of State EMS Officials at www.nasemso.org, more than three quarters of the states in the U.S. now allow CPAP at the BLS level.
As you read this section and others throughout this supplement, you will realize the significant patient impact CPAP will have in those states where every BLS and ALS unit is capable of delivering this effective treatment modality in the field.
Make It Basic
So, what’s necessary to bring this skill to the BLS provider?
First, BLS providers must be educated about the mechanism of CPAP and have a better understanding of the disease processes for which it’s indicated. The current National Standard Curriculum for EMTs currently doesn’t include CPAP, nor does it provide the required level of education in pathophysiology. However, that shouldn’t deter states from implementing CPAP for BLS providers.
Employing a lifesaving treatment not only requires an in-depth knowledge of pathophysiology, but it also requires an astute awareness of the potential complications of the given procedure. Providers must also be given the tools to correct any unforeseen complications, such as tension pneumothorax. Monitoring EtCO2 is critical to observing how your treatment is helping your patient and should be considered on any BLS unit that would initiate CPAP.
Once Wisconsin officials decided to make CPAP a basic EMS skill, they created their own CPAP education program. This curriculum, which can be provided in two hours, includes hands-on scenarios with the service’s CPAP device. Additionally, regular and frequent refresher training should be undertaken to ensure BLS providers maintain competency in the use of CPAP and reinforce that there’s little downside to its implementation—even if administered to a patient who may not actually require it.
So, what are the indications for BLS CPAP? That’s a difficult question. There aren’t many objective physiological criteria, except for increased work of breathing. Diagnosis is often seen as outside the realm of BLS. However, the new education standards encourage a greater level of critical thinking. If this critical thinking is applied correctly, it can provide sufficient clues as to who will benefit from CPAP.
BLS providers should consider CPAP for a hemodynamically stable patient with respiratory distress and a blood pressure greater than 90 who is alert and able to follow commands. They should also consider it in the scenarios below.
To successfully implement basic CPAP, the BLS provider must be educated to look for signs of increased work of breathing, such as orthopnea, use of accessory muscles, diaphoresis and speaking in short, one- or two-word sentences. They must also be able to assess for rales and/or wheezes to differentiate heart failure from COPD.
For the patient with bronchospasm, many situations indicate the potential value
Example 1: The patient has used their own nebulizer without response. An in-line nebulizer used in conjunction with CPAP should be the next step.
Example 2: While administering a nebulizer with a T-piece, it’s obvious the patient isn’t breathing in deeply enough to inhale the bronchodilator. CPAP is indicated.
Many patients with heart failure may exhibit wheezes due to fluid accumulating outside of the bronchi causing airway narrowing (“cardiac asthma”). This may lead EMS providers to believe the patient has COPD and apply CPAP with in-line bronchodilators.
The application of CPAP with in-line bronchodilators is often instituted with the understanding that the patient is suffering from COPD. This occurs just as often with ALS providers who aren’t guided by capnography waveforms as it does with BLS providers.
The administration of beta agonists to patients with acute heart failure is discouraged due to the increased oxygen demand they place on the heart. However, the value of CPAP here is enormous and may outweigh the possible complications of beta agonist administration.
CPAP is a useful therapy that can be safely initiated by EMTs after appropriate education. A majority of the U.S. states have recognized this fact and now allow BLS personnel to administer CPAP. This simple therapy can provide huge benefits for patients who rely on BLS services for their EMS care.
It can also offer earlier care and relief of respiratory distress in rural areas or regions where ALS resources are limited, and it can free up valuable ALS units to respond to other patients who need advanced care and medications.
Salpeter SR, Ormiston TM & Salpeter EE. Cardiovascular effects of ß-agonists in patients with asthma and COPD: A meta-analysis. Chest. 2004;125;2309–2321.
This article originally appeared in the January 2011 JEMS supplement “CPAP: The push for rapid relief” as “Bring It to Basics: EMT-B success with CPAP requires education & training.”