Developed by: Lynn Wittwer, MD, MPD Marc Muhr, EMT-P TJ Bishop, EMT-P Clark County EMS

1. Continuous Positive Airway Pressure (CPAP) Washington State Department of HealthEMT Basic Curriculum Developed by: Lynn Wittwer, MD, MPD Marc Muhr, EMT-P TJ Bishop, EMT-P Clark County EMS Keith Wesley, MD, EMS Medical Director State of Wisconsin

2. CPAP Curriculum – EMT Basic • Introduction • Review of Anatomy and Physiology • CPAP Overview • Pulse Oximetry • Review of Respiratory Distress • Treatment With CPAP

3. What is CPAP? • Continuous Positive Airway Pressure (CPAP) • A non-invasive alternative to intubation • Does not require any sedation • It provides comfort to the patient with acute respiratory distress by reducing work of breathing

4. Why CPAP? • Respiratory Distress is a common reason why people call 911! • Established therapeutic alternative • Easily applied, easily discontinued

5. Key Points of CPAP • CPAP has been successfully demonstrated as an effective adjunct in the management of a variety of respiratory distress states. • CPAP may prove to be a viable alternative in many patients previously requiring endotracheal intubation by prehospital personnel.

6. CPAP Non-invasive Easily discontinued Easily adjusted Use by EMT-B Does not require sedation Comfortable Intubation Invasive Usually don’t extubate in field Potential for infection Requires highly trained personnel Can require sedation Traumatic CPAP vs. Intubation

7. Review of Anatomy & Physiology

8. UPPER AIRWAY Nares Nasopharynx Oropharynx Tongue Epiglottis/Glottis Vocal Cords LOWER AIRWAY Trachea/Esophagus Carina Main stem Bronchi Secondary Bronchi Bronchioles Alveoli Elements of the Airway

9. Upper Airway

10. Pharynx • Nasopharynx • Uppermost portion of airway, just behind nasal cavities • Nasal septum • Vestibule • Olfactory membranes • Sinuses • Oropharynx • Begins at the level of the uvula and extends down to the epiglottis • Opens into the oral cavity

11. Larynx • Three main functions: • Air passageway between the pharynx and lungs • Prevents solids and liquids from entering the respiratory tree • Involved in speech production

12. Larynx • An outer casing of nine cartilages • Thyroid cartilage • Cricoid cartilage • Only complete cartilaginous ring in the larynx • Epiglottis • Hyoid bone • Cricothyroid membrane • Vocal cords

13. Lower Airway

15. Lungs • Principal function is respiration • Attached to heart by pulmonary arteries and veins • Separated by mediastinum and its contents • Base of each lung rests on the diaphragm • Apex extends 2.5 cm above each clavicle

16. Pleural Cavity • A separate pleural cavity surrounds each lung • Two layers (visceral and parietal) • Pleural space

17. Respiratory System - Physiology • The respiratory system functions as a gas exchange system • Oxygen is diffused into the bloodstream for use in cellular metabolism

18. Respiratory System - Physiology • Wastes, including carbon dioxide, are excreted from the body via the respiratory system

19. Ventilation • Ventilation refers to the process of air movement in and out of the lungs • The volume of air moved in each breath is the tidal volume • The volume still remaining in the chest after exhalation is the functional reserve capacity. FRC

20. Inspiration and Expiration • Inspiration • Chest wall expands • Lung space increases • Pressure gradient causes gas to flow into the lungs • Expiration • Chest wall relaxes • Elastic recoil causes thorax and lung space to decrease in size • Pressure gradient created in thoracic cavity causes air to move out of the chest

21. Pressure Changes During Inspiration and Expiration

22. Mechanics of Breathing

23. Mechanics of Respiration

24. Ventilation • The following must be intact for ventilation to occur: • Neurologic control to initiate ventilation • Nerves between the brainstem and the muscles of respiration • Functional diaphragm and intercostal muscles • A patent upper airway • A functional lower airway • Alveoli that are functional and not collapsed

25. Diffusion • In order for diffusion to occur, the following must be intact: • Alveolar and capillary walls that are not thickened • Interstitial space between the alveoli and capillary wall that is not enlarged or filled with fluid

26. How does CPAP work • Splints the upper airway preventing collapse • Uses continuous oxygen flow with pressure to push air into the lungs and push the fluid into the bloodsteam • Recruits alveoli that have collapsed

27. CPAP Mechanism • Increases pressure within airway. • Airways at risk for collapse from excess fluid are stented open. • Gas exchange is maintained • Increased work of breathing is minimized

28. Pulse Oximetry • Basic concept of Pulse Oximetry monitoring. • Objectively determines oxygenation status when applied correctly. • Measures the hemoglobin saturation in the bloodstream • via red and infrared light, through the skin to the arterial bed.

29. Pulse Oximetry • Possible invalid readings • Low blood flow states, (i.e., shock states, hypothermic, hypovolemia) may show an inaccurate low oxygenation percent. • Carbon monoxide poisoning may show a false high percent reading. • Anemias and oxygen capacity carrying diseases (i.e., sickle cell) may also show a false high reading. • Fingernail polish, excessive grease and dirt, nail-tips, or gel nails may cause a false low reading.

30. Review of Respiratory Distress

31. Respiratory Distress • Work of Breathing • Respiratory rate greater than 25/minute • The presence of retractions and/or use of accessory muscles • Appearance = Mental Status • Pulse Oximetry < 94% • Effects of hypoxia and hypercarbia indistinguishable • Circulation/Skin Color • Severe cyanosis • Pallor and diaphoresis

32. Focused History and Physical • Ascertain the patient’s chief complaint that may include: • Dyspnea • Chest pain • Cough • Productive • Non-productive • Hemoptysis • Wheezing • Signs of infection • Fever, chills • Increased sputum production

33. History • Previous experiences with similar/identical symptoms • Known pulmonary diagnosis • Medication history • Current medications • Medication allergies • Pulmonary medications • Cardiac-related drugs • History of the present episode • Exposure and smoking history

34. Pulmonary Edema – Congestive Heart Failure • Defined • Fluid which collects in the lung tissue and alveoli • Signs/Symptoms/Assessment • Anxious, Pale, Clammy, Dyspnea, Tachypnea, Confusion, Edema, Hypertension, Diaphoretic • Rales, Ronchi, Tachycardia, JVD, Pink Frothy Sputum, Cyanosis

35. Pulmonary Edema – Congestive Heart Failure • Signs/Symptoms/Assessment • Fatigue • Nocturia • Dyspnea on exertion • Paroxysmal nocturnal dyspnea • Chest Pain • Orthopnea

36. Pulmonary Edema – Congestive Heart Failure • Treatment • Focused history and physical exam • Complains of trouble breathing. • Airway control w/ adequate ventilation • Oxygenation • Has a prescribed nitroglycerine available. • Consult medical direction. • Facilitate administration of nitroglycerine • Baseline vital signs. • Reassess

37. Chronic Obstructive Pulmonary Disease (COPD) • Defined • Lung tissue loses elasticity secondary to destruction of the alveoli (Emphysema) • Inflammation of the bronchial tree. Diagnosed by productive cough which lasts at least three months a year for at least two consecutive years (Chronic Bronchitis) • Any COPD patient may have both

38. Chronic Obstructive Pulmonary Disease (COPD) • Signs/Symptoms/Assessment • Exertional dyspnea • Productive cough/wheezing • Minor hemoptysis • Tachypnea/exertional muscle use • Pursed lip exhalation • May have coarse crackles • Accessory muscle use • Hyperexpansion of the thorax (diminished breath sounds) • Excessive caloric expenditure

39. Chronic Obstructive Pulmonary Disease (COPD) • Signs/Symptoms/Assessment • Tachypnea, cyanosis, agitation, tachycardia, hypertension • Confusion, tremor, stupor, apnea

40. Chronic Obstructive Pulmonary Disease (COPD) • Treatment • Focused history and physical exam • Complains of trouble breathing. • Airway control w/ adequate ventilation • Oxygenation • Has a prescribed inhaler available. • Consult medical direction. • Facilitate administration of inhaler • Repeat as indicated. • Baseline vital signs. • Reassess

41. Asthma • Defined • Condition which causes the bronchi to constrict making it difficult to exhale (air trapping) • May be caused by allergic reactions and/or emotional distress • The most serious form, status asthmaticus, is a true life-threatening emergency

42. Asthma • Signs/Symptoms/Assessment • Dyspnea, chest tightness, wheezing, and cough • Obvious SOB, wheezing, accessory muscle use, paradoxical respirations, hyperresonance, prolonged expiration • Change in Mental Status: agitation, confusion, lethargy, exhaustion • Cardiac Arrhythmias

43. Asthma • Treatment • Focused history and physical exam • Complains of trouble breathing. • Airway control w/ adequate ventilation • Oxygenation • Has a prescribed inhaler available. • Consult medical direction. • Facilitate administration of inhaler • Repeat as indicated. • Baseline vital signs. • Reassess

44. Pneumonia • Defined • Inflammation of both the bronchioles and alveoli • May be viral, bacterial, or fungal. Spread by droplets or contact with infected person • Common cause of death in North America

45. Pneumonia • Signs/Symptoms/Assessment • Acute onset of chills, fever, dyspnea, pleuritic chest pain, cough, adventitious breath sounds. • In geriatric patients, the primary sign may be an altered mental state.

46. Pneumonia • Treatment • Focused history and physical exam • Complains of trouble breathing. • Airway control w/ adequate ventilation • Oxygenation • Has a prescribed inhaler available. • Consult medical direction. • Facilitate administration of inhaler • Repeat as indicated. • Baseline vital signs. • Reassess

47. Treatment with CPAP

48. Essential Components Of A CPAP System 1. CPAP Control Unit

49. Essential Components Of A CPAP System 2. Breathing Circuit and Positive Pressure Face Mask

50. Essential Components Of A CPAP System 3. Oxygen Source