CONTINUOUS POSITIVE

AIRWAY PRESSURE

CPAP
 Objectives
• Define CPAP
• Understand pathophysiology
• EMS applications
• Protocol implementation
 What is CPAP???
• CPAP increases pressure in the lungs and holds
open collapsed alveoli, pushes more oxygen
across the alveolar membrane, and forces
interstitial fluid back into the pulmonary
vasculature.
• This improves oxygenation, ventilation and ease
of breathing.
• The increased intrathoracic pressure decreases
venous return to the heart and reduces the
overwhelming preload (pressure in the ventricles
at the end of diastole).
• This lowers the pressure that the heart must
pump against (afterload), both of which improve
left ventricular function.
 So why does oxygen pass into the blood?

Pressure Gradient
Deoxygenated blood has a lower partial pressure of oxygen
than alveolar air so oxygen transfers from the air into the
blood.
 CPAP alters the pressure gradient!

7.5cm H20 CPAP

1cm H2O is equal to 0.735mm Hg.

7.5cm H2O CPAP increases the partial pressure of the

alveolar air by approximately 1%.

This increase in partial pressure ‘forces’ more oxygen

into the blood.

Even this comparatively small change is enough to

make a clinical difference.
 Perfusion
• Refers to the process of circulating blood
through the pulmonary capillary bed
• In order for perfusion to occur, the
following must be intact:
– A properly functioning heart (pump)
– Proper vascular “size”
– Adequate blood volume / hemoglobin
The Requirements Of CPAP

 The real requirement is for Continuous

CONSTANT Positive Airway Pressure

 A stable airway pressure as prescribed in order to

reduce work of breathing (WOB)
CPAP is oxygen therapy in
its most efficient form.
 Simple Masks

 Venturi Masks

 Humidifiers

 CPAP
Important Aim Of CPAP Is To
Increase Functional Residual
Capacity (FRC)

 Volume of gas remaining in lungs at end-

expiration

 CPAP distends alveoli preventing collapse on

expiration

 Greater surface area improves gas exchange

Physiological Effects Of
CPAP
 Increases PSO2

 Increases FRC

 Reduces work of breathing

Indications for Use
• Treatment of severe
respiratory distress
CHF/COPD/Asthma
• RR>25 bpm
• Retractions, accessory muscle
use or fatigue
• SAO2 < 94% at any time
• Near drowning
• Pt must be able to maintain
own airway and be able to
follow commands.
 Exclusion Criteria
• BP <90 mmHg • Unable to obtain
• Unconscious adequate seal
• Inadequate • Pnuemothorax
respiratory rate • Active emesis
• Cardiac arrest
CPAP And Pulmonary Edema
 Severe pulmonary edema is a frequent cause of
respiratory failure
 CPAP increases functional residual capacity
 CPAP increases transpulmonary pressure
 CPAP improves lung compliance
 CPAP improves arterial blood oxygenation
 CPAP redistributes extravascular lung water

(Rasanen 1985)
Redistribution Of Extravascular
Lung Water With CPAP
 Benefits/Advantages of CPAP
• CPAP reduces work of breathing by
keeping the “wet” alveoli open
• If the alveoli are open at the end of
expiration, energy is not consumed on the
next inhalation
• Work of breathing is reduced relieving
respiratory muscle fatigue
 Benefits/Advantages of CPAP
• A higher alveoli pressure will result in a
stoppage of fluid movement into the
alveoli
• Increase in airway pressure results in
improved gas exchange
 CPAP And Acute Respiratory
Failure
 CPAP overcomes inspiratory work imposed by auto-peep

 CPAP prevents airway collapse during exhalation

 CPAP improves arterial blood gas values

 CPAP may avoid intubation and mechanical ventilation

(Miro 1993)
WHAT ABOUT THE
EMPHYSEMA PATIENT?
 Important Point
• Emphysema
patients do not
respond
predictably to
CPAP
 As a general rule…
• The larger the “barrel chest” and the more
pronounced the accessory muscles, the
more caution we should use with CPAP
 What is needed for CPAP
application.
• Oxygen source capable of producing 50 psi.

• Flow regulator which delivers either a fixed oxygen concentration

at 30% or an adjustable flow regulator.
– Venturi
– Micro channels

• Tight fitting mask to which the oxygen/air mixture output of the

generator is attached and applied to the patient.

• Positive End-Expiratory Pressure (PEEP) valve connected to the

exhalation port which maintains a constant pressure in the circuit.

• What are some signs and symptoms of

respiratory distress??
 What is needed for CPAP
application.
• Oxygen source capable of producing 50 psi.

• Flow regulator which delivers either a fixed oxygen concentration

at 30% or an adjustable flow regulator.
– Venturi
– Micro channels

• Tight fitting mask to which the oxygen/air mixture output of the

generator is attached and applied to the patient.

• Positive End-Expiratory Pressure (PEEP) valve connected to the

exhalation port which maintains a constant pressure in the circuit.

• What are some signs and symptoms of

respiratory distress??
 CPAP Contraindications
• CPAP may be contraindicated for patients with
any of these conditions:
– Unconscious
– Apnea
– Pneumothorax
– Decreased cardiac output and gastric
distention
– Severe facial injury
– Hypotension secondary to hypovolemia
– Uncontrolled vomiting
Explain the Procedure to your
Patient
• Explain to your patient that in order to get
the best possible results from a CPAP
device. Ask them to inhale through the
nose and exhale through the mouth
against the pressure produced by the
CPAP machine.

• If they do not know what to expect, it is

similar to the air felt when sticking your
head out of the car window when moving.
 The Whisperflow
• Here is a step by step review of the operation
of the Whisperflow CPAP device.

• Properly assess
pt for baseline
Pulse Oximetry

• Attach high pressure hose to portable tank

using short adapter hose. It may be best to
load the patient first
and start CPAP early in the transport:
conserves portable tank
for ER transfer.

• Assemble mask and tubing, don't forget to

place the
filter on air intake of the CPAP device
 The Whisperflow
Explain the
procedure to the
Prepare mask, patient. Turn the
strap unit on (all the
rearrangement way) & turn the
might be FLOW on (all the
necessary way)
Have the patient place the mask
on his/her face tightly. Some
"coaching" will help the patient
transition from holding the mask
near their face to creating a
seal. It's OK for the patient to
hold the mask without using the
straps if they're more comfortable
that way. When he is comfortable
with the feeling of the mask
you may secure it to his head
tightly so that no leaks are
noticed.
 Final Application Steps
After loading the
Next you'll need patient to the
to fine-tune the unit you'll need
unit by to
decreasing the transfer to the
FLOW until a onboard oxygen.
slight outward Do it quickly -
flow is felt while turn on the main
the patient first!
inhales.
You can easily add nebulized By using the patient's pulse-ox
albuterol to the level as a guide you may adjust
patient's treatment by cutting the amount of oxygen up to
the tubing at a joint
achieve desired oxygen
and inserting a 'T' and
nebulizer with saturation, usually 90 -93%.
6 liters oxygen attached.
If the mask is not tolerated
after coaching…remove it!!!
 A few things to
remember...
• When the flow valve is open all the way, with the
oxygen valve closed, you are giving the patient
28% oxygen and a portable tank will last quite
some time!
• By increasing the oxygen flow, you'll use more
liters per minute - as much as 140! Be careful,
you'll run out!
• If you reach the point that air is blowing out of
the air intake on the device your oxygen flow is
too high.
• When swapping from portable to main oxygen
tanks warn the patient that the flow will stop for a
few seconds but they will still be able to breathe,
then swap quickly!
 Oxygen Tanks
At 28-30% FiO2 , a full tank should last
approximately:

• D cylinder=28 minutes
• E cylinder=40-50 minutes
• M cylinder=about 4 hours

• FiO2 is fraction of inspired oxygen.

(at 100% FiO2 a D cylinder tank will last approximately 3-4 minutes. Use
what you need, but be prepared with additional cylinders)
 Case Study for CPAP

You are called to a 76-year old male who is complaining

of dyspnea. Upon arrival, you find the patient sitting
on a chair leaning forward. He is diaphoretic,
cyanotic and has a respiratory rate of 48. Upon
auscultation you hear fine crackles throughout both
lung fields and he is hypertensive.

http://www.eresp.com/CPAPosSim.swf
 Works Cited and Thank
You
Thank you to EMS Personnel at Dallas Ambulance, ST Paul Fire, Salem Fire, Rural Metro,
Washington Co EMS, MTCI, Albany Fire, Marion County, and Mercy Flights for sharing
information regarding CPAP. The following websites were also use as resources.

• http://www.dhfs.state.wi.us/ems/EMSsection/Protocols/CPAP/CPAP_Protocol.pdf
• http://www.ems1.com/columnists/dan-white/articles/390898-A-Look-at-CPAP-for-EMS
• http://caradyne.respironics.com/whisperflow.htm
• http://phillydan.spaces.live.com/Blog/cns!B2AD15EED4F62B2B!236.entry
• http://elearning.respironics.com/main_ProdTrainCourse_pr.asp
• http://www.jcems.net/cgi-bin/news.cgi
• http://www.eresp.com/CPAPosSim.swf
• http://www.miamitwp.org/fireems/training/skill_sheet_ems.htm
• http://www.emsresponder.com/features/article.jsp?id=1738&siteSection=16
• http://www.maconnc.org/ems/CPAP.html
• http://www.merginet.com/index.cfm?pg=airway&fn=CPAPuser
• http://emsstaff.buncombecounty.org/inhousetraining/cpap/cpap_overview2.htm
• http://www.doctorfowler.com/lecturepage.shtml
Questions and answers