4. CPAP

My # 4 greatest treatment change in the last twenty years is CPAP.

Here is what I wrote shortly after using it the first time back in 2007:

CPAP

This morning we had a call for a 70 year old man with dsypnea and found him guppy-breathing with a BP of 210/100, HR – 144, skin ice cool and clammy, unable to get a SAT, ETCO2 of 50, RR of 32. Wheezes and crackles in lungs. Upright CO2 wave form.
He was sitting on his front steps, probably hoping the fresh air would help, but it wasn’t. We threw him on the stretcher and got him in the back of the ambulance quick.
We put him on CPAP — first time for me (we’ve only had it a couple weeks) — and started pounding in the nitros and in no time he was warm and dry. RR down to 24, ETCO2 down to 34. HR down to 132. He was still full of fluid, but at least we weren’t having to intubate him. Neither did the hospital. They put him on bi-pap and a nitro drip. His PH was 7.25 on arrival. The doctor said he probably would have coded if we hadn’t gotten there and started treating him as soon as we did.

I was trying to imagine how the call would have gone if we didn’t have CPAP. The nonrebreather wouldn’t have helped much. We had it on for about a minute before we got the CPAP out and he was tearing it off gasping that he couldn’t breathe. We would have had to start bagging him and maybe dropped a tube – certainly much more invasive than putting the CPAP on.

I saw him later in the hospital and they had him down to a Venturi mask and he was sleeping comfortably.

I made sure to thank our medical control doctor and clinical coordinator for helping us get CPAP. It certainly made a big difference — just as advertised.

In the five years since we first got CPAP, I have used it probably two dozen times, with many just as dramatic as the above. As a region we have expanded our use of CPAP from just for pulmonary edema to any severe dyspnea. If it works, keep it on. If it doesn’t, take it off. My least favorite calls were the severe dyspnea where you had to battle with the patient just to help them, but CPAP has made it so much less stressful. We can also give Ativan on standing orders now to patients with anxiety due to their dsypnea. It makes it much easier to get them to cooperate.

Studies have shown that the use of CPAP prehospitally reduces the need for intubation by 30% and reduces mortality by 20%. – “Out of Hospital Continuous Positive Airway Pressure Ventilation Versus Usual Care in Acute Respiratory Failure: A Randomized Controlled Trial.” Annals of Emergency Medicine. September 2008

So the number to treat to save one life is 5. That means for every 5 times you use it, you are saving one patient who might have otherwise died. That speaks for itself.

In Connecticut we are pushing to make this a BLS skill with medical control approval.

***

16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic

Capnography
6. Termination of Rescusitation Guidelines
7. Decreased Use of Lights and Sirens
8. Selective Spinal Immobilization Guidelines
9. Alternative Airways
10. Chemical Restraint
11. No More Lasix
12. EZ-IO
13. Permissive Hypotension
14.Expanded Medication Routes, Less IV Emphasis
15. Narrower Use of Narcan
16. Increased Standing Orders

1 Comment

  • Bill Anderson says:

    The first time I used it it amased me as to how well it worked. I had a NH patient with SaO2 in the 60′s, loud, gurgling respirations, and using accessory muscles. They had her on the usual 3lpm via NRB. I put her on high flow and headed for the truck. Got my line, gave her 80 of Lasix(we still use it), 1.25 Enalapril, and CPAP. By the time we got to the hospital she had slowed her breathing down, breath sounds were better, and was speaking 4 word sentences. I had her sitting upright, and the ER staff laid her down flat and undid every thing I had accomplished(second time I’ve had an ER do this). She started having dyspnea and desatting. They were surprized that we(private service) had CPAP. Fire department didn’t at the time.

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Peter Canning

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