Two years ago, I attended a meeting where several EMS medical directors were discussing the implementation of continuous positive airway pressure (CPAP) in their systems. Many were already seeing the significant benefits of CPAP. One reported his system had already reduced the number of patients requiring endotracheal (ET) intubation in the field by 79%. He felt CPAP kept many elderly patients from becoming ventilator-dependent and from “never getting off the vent.”
Non-invasive pressure-support ventilation (NIPSV), a method of assisting a patient’s respiration without intubation, was first reported in the 18th century. Used in the 1930s for patients with pulmonary edema and in the 1950s for those with polio, NIPSV is currently delivered through CPAP or bi-level positive airway pressure (BiPAP) devices.
I. CPAP & CHF
The primary goal of CPAP is to decrease the work of breathing so the patient doesn’t deteriorate, doesn’t require intubation—which is associated with increased mortality—and doesn’t suffer respiratory arrest. Patients who are intubated are as much as seven times more likely to die than those who are not.(1)
Several studies have demonstrated that instituting CPAP in the field reduces the
need for intubation by as much as 60%.(1,2)
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.
When it comes to choosing a CPAP device, there are a host of designs and options available.
1. Type of flow
CPAP devices are one of two types: those that run constantly and those that flow only when the pressure drops below a certain level. The constant-flow devices provide CPAP by ensuring that there’s more air/oxygen flow than the circuit and mask can accommodate. The excess is vented through the PEEP valve.
No CPAP device will accomplish its goal if the patient can’t tolerate its application. To facilitate successful use, consider the following tips.
Don’t start with the Head Straps
Every EMS service should have patient care protocols and procedures in place that clearly outline the role of CPAP in their care of patients. The following are examples of indications, contraindications, precautions and procedures that you may be able to use for your service. These examples should be modified to meet your scope of practice and approved by your medical director. To obtain the actual EMS system protocols, go online to www.jems.com/CPAPprotocols.
HealthEast (Minn.) Medical Transportation Procedure