CPAP Best Practices

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

HealthEast (Minn.) Medical Transportation Procedure
CPAP has been shown to rapidly improve vital signs, gas exchange, work of breathing, decrease the sense of dyspnea and the need for endotracheal intubation in patients who suffer shortness of breath from asthma, COPD, pulmonary edema, CHF and pneumonia. In patients with CHF, CPAP improves hemodynamics by reducing preload and afterload.

“¢    Has shortness of breath (for reasons other than trauma)
“¢    Is awake and able to follow commands
“¢    Is of an age able to fit the CPAP mask
“¢    Has a respiratory rate greater than 26 breaths per minute
“¢    Has a systolic blood pressure above 90 mmHg (CPAP may raise intrathoracic pressures, reducing preload, therefore reducing blood pressure even further)
“¢    Has been using accessory muscles during respirations
“¢    Presented signs and symptoms consistent with asthma, COPD, pulmonary edema, CHF or pneumonia.

1.    Patient is in respiratory arrest
2.    Patient is suspected of having a pneumothorax
3.    Patient has a tracheostomy
4.    Patient is vomiting

Use care if patient:
“¢    Has impaired mental status and is not able to cooperate with the procedure
“¢    Has failed at past attempts at non-invasive ventilation
“¢    Has active upper gastrointestinal bleeding or history of recent gastric surgery
“¢    Complains of nausea or vomiting
“¢    Has inadequate respiratory effort
“¢    Has excessive secretions
“¢    Has a facial deformity that prevents the use of CPAP

1.    Explain the procedure to the patient.
2    Ensure adequate oxygen supply to ventilation device.
3.    Place the patient on continuous pulse oximetry, continuous EtCO2 and cardiac monitoring.
4.    Place the delivery device over the mouth and nose.
5.    Secure the mask with provided straps or other devices.
5.    Use 5.0 cm H2O of PEEP (pressure may be titrated up to 15 cm H2O
as needed.)
7.    Check for air leaks.
8.    Monitor and document the patient’s respiratory response to treatment.
9.    Monitor vital signs at least every five minutes. CPAP can cause BP to drop.
10.    Continue to coach patient to keep mask in place and readjust as needed.
11.    Remove device and consider intermittent positive pressure ventilation with or without endotracheal intubation if respiratory status deteriorates.

Removal Procedure
1.    CPAP therapy needs to be continuous and shouldn’t be removed unless the patient can’t tolerate the mask or experiences continued or worsening respiratory failure.
2.    Intermittent positive pressure ventilation and/or intubation should be considered if the patient is removed from CPAP therapy.

Pediatric Considerations
CPAP should be used with caution in children under 12 years of age and should start with lower pressures
(2 cm H2O).

Special Notes
“¢    An in-line bronchodilator nebulizer may be placed in CPAP circuit if needed.
“¢    Don’t remove the CPAP device until hospital therapy is ready to be placed on patient.
“¢    Most patients will improve in five to 10 minutes. If there’s no improvement within this time, consider increasing pressure and preparing for drug-facilitated airway management.
“¢    Watch patient for gastric distention (often presents as vomiting in conscious patient).
“¢    Use nitroglycerin infusion rather than spray to prevent breaking CPAP seal or dispersal of medication on rescuers.
“¢    Remember that CPAP application doesn’t violate “do not resuscitate” or “do not intubate” orders.
“¢    Consider the ALS administration of Ativan for anxiety associated with CPAP use, bearing in mind that Ativan may result in respiratory suppression.

Bellingham, Wash., Procedure
Setting up the CPAP system
1.    Connect the generator to the oxygen source (tank or wall outlet) via quick connect. Don’t attach to a flow meter; it must be a 50-psi source.
2.    Attach the filter on the air entrainment (air intake) port.
3.    Attach the corrugated tubing to the WhisperFlow generator.
4.    Select the appropriately sized mask (large for most adults, small for very small adults and children), and attach the mask to corrugated tubing.
5.    Attach the CPAP valve to the center hole of the mask.
6.    Attach the strap to the mask.

Adjusting flow and Fi02 on the WhisperFlow generator
1.    Turn all three control knobs fully clockwise to the “off” position.
2.    Turn the flow adjustment valve counter-clockwise to the completely open position (about five complete turns) to provide full flow (140 liters per minute).
3.    Turn the oxygen control valve to the fully closed position (28%). If after five minutes, the patient’s SpO2 isn’t at the desired level, you may deliver higher oxygen concentrations (up to 100%) by turning the valve farther counter-clockwise. The FiO2 should be increased judiciously to preserve O2. Then evaluate the SpO2.
4.    Turn the on/off valve to the “on” position.
5.    Verify that air is flowing to the mask.
6.    Leave the oxygen and flow controls as you’ve set them. Then turn the on/off valve fully off (clockwise).

Apply the mask
1.    When you’re ready to apply the mask to the patient, turn the on/off valve fully on (counter-clockwise 1/2 turn), be sure the gas is flowing, and then hold the mask on the patient’s face. It will help to put one hand on the back of the patient’s head and one on the mask to be sure you are applying just enough pressure to keep a good air seal.
2.    Within a few minutes, when the patient is comfortable, use the head strap to hold the mask in place.  Ensure that it isn’t too tight. Some air leakage is acceptable unless it’s in the eye area.
3.    Make sure you are providing flow in excess of the patient’s inspiratory flow rate in order to maintain continuous pressure throughout the breathing cycle. This should be checked frequently during transport, as the patient’s needs may change. There are three ways to determine whether your flow is set high enough:
    “¢    The CPAP valve should remain slightly open during the entire respiratory cycle.
    “¢    The anti-asphyxia valve on the mask shouldn’t open during normal operation.
    “¢    You should be able to feel some gas escaping from the exhalation port of the CPAP valve even during inspiration.
4.    For patient comfort and to preserve oxygen, turn the flow adjustment knob down to maintain the flow just above the patient’s flow rate.
5.    Normally, the patient should improve in the first five minutes with CPAP, as evidenced by the following:
    “¢    decreased heart rate;
    “¢    decreased respiratory rate;
    “¢    decreased blood pressure; and
    “¢    increased O2 sat.

Well-written protocols, which clearly state the point in care at which CPAP should be administered–combined with close monitoring–will ensure that CPAP is used in the most appropriate manner and that patients in severe respiratory distress will reap the benefits of this wonderful life-saving skill.

This article originally appeared in the January 2011 JEMS supplement “CPAP: The push for rapid relief” as “Best Practices: CPAP protocols and quality improvement.”

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