CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)

Originated 02/01/2010

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LEVEL OF AUTHORIZATION:
All Levels

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

DESIRED EFFECTS:
CPAP is a non-invasive procedure designed to improve lung mechanics by improving compliance and increasing pressure within the airway, and by a reduction of the work of breathing (WOB). By avoiding unnecessary intubation, length of hospital/ICU admission is reduced, risk of nosocomial infection is reduced, and overall patient outcome is improved.
INDICATIONS:

1. Acute respiratory distress in patients with severe CHF/cardiogenic pulmonary edema, COPD, asthma, or pneumonia with systolic blood pressure (SBP) >100mmHg.
2. MUST be awake and able to follow commands and MUST have the ability to maintain a patent airway

CONTRAINDICATIONS:

1. The patient may refuse this treatment at any time. Be sure to document in PCR patient's consent/refusal of CPAP when indicated.
2. Inability to maintain a patent airway.
3. Inability to use mask (e.g. uncooperative patient, head or facial trauma, or facial anomalies)
4. Immediate need for intubation (e.g. respiratory and/or cardiac arrest)
5. Profound diminished level of response
6. Hemodynamic instability (SBP < 100mmHg) or life-threatening arrhythmia
7. Active vomiting or upper GI bleed
8. Excessive excretions
9. Tracheostomy
10. Chest trauma or suspected pneumothorax

PROCEDURE:

1. Follow the appropriate respiratory emergency treatment guideline.
2. EXPLAIN THE PROCEDURE TO THE PATIENT!!! Allow them to refuse if they so choose. Document in your PCR if they provide consent or refuse.
3. Optimally, place the patient in an upright and seated position. Alternatively, position the head of bed at a 45 degree angle.

CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) (continued)

4. Continually reassess and document vital signs and respiratory effort every 5 minutes. Cardiac monitoring MUST be performed throughout the procedure.
5. Apply CPAP operating system (CPAPos) and titrate to a maximum of 10cm H2O
6. Monitor patient for gastric distention and cardiac arrhythmia.
7. Treatment should be given continuously throughout transport to ED.
8. For acute CHF/cardiogenic pulmonary edema with SBP >100mmHg, administer NITROGLYCERIN OINTMENT [1/2" to 1"] to patient's upper chest via applicator pad and tape in place. Document time and amount applied.
9. For acute asthma/COPD, administer ALBUTEROL and/or IPRATROPRIUM per protocol through in-line nebulizer.
10. Continually assess patient for changes and need for additional interventions and/or medications.
11. In the event of life-threatening complications:
• Stop treatment
• Offer reassurance.
• Institute BLS/ALS support as appropriate.
12. Notify receiving facility early to prepare for appropriate pulmonary support.
13. DO NOT leave patient unattended while CPAP is in place.

 SPECIAL NOTES:

1. Unless patient condition deteriorates, CPAP must remain applied to patient once initiated (i.e. including transfer to and from ambulance and during transport). Do not remove CPAP from patient until the receiving facility is ready to provide appropriate ventilatory support.
2. Ensure that you have a full oxygen cylinder.
3. Monitor patient closely for gastric distention, which may result in vomiting and/or increased intrathoracic pressure.
4. Explain to the patient that they have the right to refuse CPAP at any time. Proper documentation stating their consent or refusal of treatment must follow in your PCR.
5. Use of CPAP, patient's clinical response, and CPAP pressure must be documented in patient care report, as well as any complications or need to discontinue CPAP.