At the beginning of my career, numerous times per day, we slung Lasix at congestive heart failure (CHF) patients and hurried them to the hospital. They were suffocating and attempting to breathe with every bit of energy they could muster. “Would you like me to breathe for you?” we would ask. Sometimes a patient said, “Yes.” Sometimes that was the last word out of the person’s mouth.
What if we had a stopgap between oxygen and rapid sequence intubation? Maybe something noninvasive but that packed a punch?
Not too long after that point in time, continuous positive airway pressure (CPAP) made its way into my agency’s protocols, and things changed.
Patient panic, then relief
CPAP is a member of the non-invasive positive pressure ventilation (NIPPV) family. Physiologically, CPAP keeps the alveoli that are at the end of the bronchioles expanded and forces pulmonary edema fluid back into the vascular space by displacing the fluid with pressurized air on a breathing patient. Positive end-expiratory pressure is what is measured during the application of CPAP and most likely is increased until the patient shows signs of improvement.
Think back to when you were in an EMT class and you were doing a “bag a buddy” drill. You practiced bagging friends and getting them relaxed with your assisted ventilations. Do you remember when they bagged you on the expiratory portion? Until they figured out the rhythm over three or four breaths, it was slightly difficult for you to breathe against that pressure, right? It can be terrifying to some. However, for people who experience a CHF exacerbation or another ventilatory-based illness, this could be the breath of fresh air that they wanted. The problem is getting them to that point.
Making a difference
A CPAP mask is like a bag-valve mask but more comfortable and with straps that hold it onto the patient’s face. A valve assembly that has an oxygen hose goes to a tank. (If you’re lucky and have ventilators, the tubing would go to that.) All of this can be very intimidating for patients who already are terrified that they can’t breathe.
The goal is to talk them down. Be soothing. Make the environment as comfortable as you can in an effort to assist with the application of the device.
In ALS cases, you can consider delayed sequence intubation, using ketamine to calm the person who is wearing the CPAP. This gives you the ability to try CPAP to see whether it works, as a means of hopefully negating the need to intubate, and you just can observe the patient getting better.
Over the years, we have grown our practice in our rural county to where our protocols allow EMT-Bs to provide CPAP for respiratory distress patients. We have had fantastic results. Because of our long en route and transport times, local volunteer departments have made a difference in a crashing respiratory patient myriad times.
More than just transport
New devices are coming out regularly, and the technology keeps evolving. Obviously, the best option is a portable ventilator with NIPPV functions, but those are expensive.
There are single-use products that have CPAP. (There are ones that have bilevel-positive airway pressure, but those only push in air.) The downside to many single-use CPAP systems is that they are very loud because of the massive amount of air flow that’s needed from O₂ bottles, but the technology is improving.
Remember, we are a Band Aid in the total process of the care of our patients. We must transport them to the hospital. However, with the appropriate tools and knowledge, we can be a really incredible Band Aid that potentially can fix the problem before we arrive at the emergency department doors.
If you haven’t investigated CPAP, please do. If you have it already, look into getting it to your EMTs. Any way that we can increase our abilities, we can improve treatment for our constituents.
