Overview of EMS Prehospital CPAP Devices
Noninvasive ventilation is a way of helping patients breathe by using a mask or similar device over their face instead of inserting a tube directly into their windpipe (a process called “endotracheal intubation”). This approach helps to avoid risks like pneumonia from the ventilator or damage to the airway that are related to more invasive methods.
The technique of using positive pressure to help breathing, known as Noninvasive Positive Pressure Ventilation (NIPPV), has become a regular method to help patients with difficulty breathing outside of the hospital. This method was first pioneered during the 1950s polio epidemic by Bjorn Ibsen and resulted in a major decrease in deaths. Later, in the 1980s, noninvasive ways of applying constant positive airway pressure (CPAP) were developed to treat conditions like sleep apnea and chronic obstructive pulmonary disease (COPD), which also affect breathing.
Earlier models of NIPPV used a control unit or flow generator linked to the oxygen source to create the required positive pressure. Current CPAP devices deliver a specific pressure, which can be adjusted by modifying a control valve or the flow of oxygen to produce a necessary positive pressure at the end of exhalation (Positive End-Expiratory Pressure or PEEP). These newer models cost less than the original machines and are simpler to use because all the necessary parts are integrated into the device.
Using CPAP outside of a hospital setting started to become more common in the late 1990s. It’s now seen as an alternative to putting a tube into the windpipe or using devices above the glottis (the part of the throat that leads to the windpipe), which are more invasive measures. CPAP is the most often used method of NIPPV outside the hospital and can help to reduce the effort of breathing and increase oxygen levels for patients with heart and lung issues. Using NIPPV outside the hospital has helped to decrease the instances of inserting a tube into the windpipe as well as complications like low blood pressure, low oxygen levels and heart attack. This method of helping patients breathe has become the standard care for acute breathing difficulties outside the hospital. A study shows that using this method has reduced deaths and the need for tube insertion when compared to regular care.
Anatomy and Physiology of EMS Prehospital CPAP Devices
NIPPV, or non-invasive positive pressure ventilation, is a method that helps improve lung function. It works by increasing the flexibility of the lungs, stabilizing and opening up the alveoli (small air sacs in the lungs), and reducing the effort required to breathe. NIPPV achieves this by applying two types of pressure: PEEP (Positive End-Expiratory Pressure) and IPAP (Inspiratory Positive Airway Pressure).
PEEP is beneficial in conditions like COPD (Chronic Obstructive Pulmonary Disease), where it helps prevent the alveoli from collapsing when you breathe out. This helps improve the exchange of gases (oxygen and carbon dioxide) in your lungs. In conditions like COPD or pulmonary fibrosis (scarring of the lungs), there can be an abnormal amount of residual pressure from trapped air in the lungs, known as auto-PEEP. Like PEEP, CPAP (Continuous Positive Airways Pressure) also applies constant pressure during breathing cycles, which helps prevent the alveoli from collapsing entirely when you breathe out.
The positive pressures applied by these methods enhance gas exchange and reduce fluid accumulation (edema) in the lungs. Increased pressure inside the chest helps reduce the strain on the walls of the alveoli to facilitate breathing. By increasing the surface area of the alveoli, gas exchange becomes more efficient. This enhancement of pressure also helps reduce the amount of blood returning to the heart (preload), and encourages a shift of fluid out of the lungs and back into the blood vessels of the lungs.
Why do People Need EMS Prehospital CPAP Devices
Non-Invasive Positive Pressure Ventilation (NIPPV) is a method that helps people breathe easier. NIPPV works by increasing the flexibility of the lungs and helps to open and stabilize collapsed sections of the lungs, thus improving the distribution of air in the lungs. NIPPV, specifically Continuous Positive Airway Pressure (CPAP), can help to increase the pressure within the chest making the heart work more effectively and decreasing the likelihood of fluid building up in the lungs. Health guidelines endorse the use of this breathing aid for serious flare-ups of chronic obstructive pulmonary disease (COPD) and respiratory failure due to fluid build-up in the lungs.
The use of CPAP can help in various health conditions:
- Heart failure: NIPPV can lower the chances of needing a breathing tube in patients with acute fluid build-up in the lungs due to heart failure. It lessens the strain on the heart and clears fluid from the lungs.
- Chronic lung diseases like COPD and asthma: Another type of NIPPV, called Bilevel Positive Airway Pressure (BiPAP) can reduce the effort needed to breathe and improve air flow in the lungs. This helps to prevent the condition from worsening. Even though it’s not commonly used, NIPPV can also help severe asthma flare-ups by reducing trapped air and improving ventilation in the lung.
- Acute bronchitis and pneumonia: NIPPV can aid patients, particularly those with chronic lung disease. It helps to better oxygen delivery within the body and reduces the effort needed to breathe.
- In cases of chest injuries, NIPPV can help patients with difficulties in breathing, provided they don’t have other complications such as facial fractures or a risk of inhaling foreign substances.
- In cases of harmful gas exposure, such as chlorine, severe obesity, or near drowning incidents.
- In neonates (newborn babies) with breathing difficulties and for patients with advanced or terminal illnesses who have decided not to receive resuscitation.
There are other situations where NIPPV can be beneficial:
When a Person Should Avoid EMS Prehospital CPAP Devices
Some conditions prevent the use of Non-Invasive Positive Pressure Ventilation (NIPPV). NIPPV is a treatment that helps people breathe better using air pressure. However, if a person has a heart or respiratory arrest, is in a coma, or needs immediate placement of a breathing tube, they cannot use NIPPV. It is also not suitable for cases of facial burns or injuries, or if a person is actively vomiting. Medical conditions that completely block the airway also make NIPPV impractical.
There are also situations where NIPPV might pose risks, but it is not completely forbidden. These include poor ability to clear mucus from the respiratory tract, decreased alertness or energy levels, and shock—one’s body’s response to not having enough blood flow—that needs medication support. Other examples include unstable heart rhythms, uncontrollable vomiting or bleeding, epilepsy with continuous seizures, possible blockage of the upper airway, severe allergic reactions (anaphylaxis), injuries to the windpipe, fractures to the facial bones or the base of the skull, or any external mass that is pressing against the airway.
Equipment used for EMS Prehospital CPAP Devices
Modern Continuous Positive Airway Pressure (CPAP) devices, which are used to help people who have trouble breathing, are portable and cost-effective. They include a flow generator and a PEEP valve to keep the airways open. These machines are popular withmedical professionals outside the hospital because they can be combined with a disposable face mask, making them easy to carry and use.
The air pressure on these devices typically ranges from 5 to 10 cm H2O. For instance, patients with asthma, bronchitis, and Chronic Obstructive Pulmonary Disease (COPD) usually start with a pressure of 5 cm H2O. On the other hand, those with heart failure, severe pneumonia, and lung water buildup from near-drowning experiences usually begin at 10 cm H2O.
This air pressure helps reduce the effort needed to breathe by up to 60% and can improve the endurance of the breathing muscles by up to 95%. The outcome is generally better breathing, leading to a more comfortable patient.
Who is needed to perform EMS Prehospital CPAP Devices?
Using a special kind of breathing support called NIPPV (Non-Invasive Positive Pressure Ventilation) in real-life emergency situations requires well-trained emergency medical service or EMS personnel. They need suitable equipment and understandable rules to follow. These medical professionals must be good at selecting who needs this type of support, making sure the breathing mask fits properly, and ensuring that the treatment is working properly.
In recent years, the duties of EMS workers have changed. For example, in 2018, the National Highway Traffic Safety Administration introduced a new set of responsibilities for these workers. The 2007 set of responsibilities stated that only paramedics, who are specially trained, could use two kinds of breathing support devices – CPAP (Continuous Positive Airway Pressure) and BiPAP (Bilevel Positive Airway Pressure). However, the updated 2018 responsibilities now allow EMT-Basics, who have fewer training than paramedics, to be trained in using CPAP while caring for patients. In many parts of the country, as long as they’ve received the necessary training and approval from their medical director, these EMT-Basics can use CPAP devices.
Workers providing EMS should be trained on when and when not to use NIPPV, how to apply it effectively, and how to handle common problems. They should also have guidelines that explain when to start this type of ventilation, how to monitor its effects, and what to do if NIPPV is not effective.
Preparing for EMS Prehospital CPAP Devices
If a patient has never used a Non-Invasive Positive Pressure Ventilation (NIPPV) device, which is a mask that helps them breathe, they will need some training before they start using it. Some people might feel a bit claustrophobic, or scared in small closed spaces, with a full-face mask device. That’s why guidance from healthcare professionals is so significant, not only to make patients comfortable, but also to ensure they are using the device correctly.
When a person is experiencing severe breathing difficulties, it is important for healthcare professionals to prepare the NIPPV device swiftly. Moreover, the device should be hooked up to a sufficient supply of oxygen, as most devices use a considerable amount of oxygen to work. Always pay attention to the instructions provided by the device manufacturer to use it appropriately.
How is EMS Prehospital CPAP Devices performed
Before we start using a CPAP mask, we’ll let you know how it will feel so you can be prepared and get rid of any anxiety you may feel about using it. The mask will then be put on your face, and we’ll guide you to take deep breaths. It’s important that the mask isn’t too tight as this could cause discomfort and may also cause air to leak out. We will adjust the straps to make sure the mask is comfortable on your face and sealed to prevent any leaks. We’ll also position you in a way that assists your breathing, which usually involves sitting you in a slightly upright position.
With the CPAP machine, we start at a lower pressure setting of around 5 cm H2O to allow your body time to get used to it. Little by little, we’ll increase this pressure to around 10 cm H2O. Some patients might need a higher level of CPAP. We’ll also adjust the amount of oxygen based on your SpO2 (a measurement of the oxygen level in your blood), typically starting with 2 to 4 liters per minute.
If we’re using BiPAP, we also start with lower pressures to let you acclimate. We typically set an IPAP (Inhale Positive Airway Pressure) of 10 cm H2O and an EPAP (Exhale Positive Airway Pressure) of 5 cm H2O. The general range for IPAP is 10 to 20 cm H2O, and EPAP is usually set to be between 4 to 10 cm H2O. Like with the CPAP, we’ll modify the flow of oxygen, starting at 2 to 4 liters per minute, based on your SpO2 readings.
We’ll keep a close eye on you as you use the device, monitoring your breathing, checking the sounds your lungs are making, and ensuring you’re comfortable. We will also regularly monitor your vital signs, such as your breathing rate, heart rate, blood pressure, and oxygen level in your blood, all in order to check how you’re doing. We’re looking for obvious signs of improvement like less difficulty breathing, reduced breathing rate, and stable vital signs.
Possible Complications of EMS Prehospital CPAP Devices
Complications of non-invasive positive pressure ventilation (NIPPV), a type of breathing support therapy, can include symptoms like discomfort for the patient, increased anxiety, and agitation. In some cases, more serious complications might occur, such as lung injury due to high pressure (pulmonary barotrauma) or low blood pressure (hypotension). The latter can happen because increased pressure inside the chest cavity reduces the blood that’s coming back to the heart. Furthermore, the NIPPV can sometimes cause the stomach to bloat (gastric distention), leading to a condition called abdominal compartment syndrome, where the pressure inside the abdomen increases and affects organ function. This is more likely when the pressure setting for breathing in (IPAP) is higher than 20 cm H2O.
Fortunately, many of these issues can be reduced. This can be done by using the least intense setting that still provides helpful results. For the issue of low blood pressure, a treatment option can be the use of intravenous fluids, which are administered directly into the veins.
What Else Should I Know About EMS Prehospital CPAP Devices?
Noninvasive positive pressure and Continuous Positive Airway Pressure (CPAP) ventilation can significantly reduce severe breathing difficulties caused by various factors. This type of ventilation also lowers the need for more invasive procedures, such as intubations, that can lead to complications like infections and lengthy hospital stays. Noninvasive ventilation is a key treatment for patients with heart failure and COPD (Chronic Obstructive Pulmonary Disease). Research has shown that the most significant predictor of death in COPD patients is the use and complications of invasive ventilation, so preventing the need for such procedures is crucial.
Recent studies have shown that using noninvasive positive pressure ventilation (NIPPV) before the patient arrives at the hospital greatly improves their outcomes. Specifically, NIPPV has shown to lower death rates and reduce the need for intubation. Noninvasive ventilation methods like CPAP and BiPAP (Bilevel positive airway pressure) are extremely important in managing respiratory distress in a pre-hospital setting. These methods have shown positive results in conditions like heart failure, COPD, and possibly asthma and pneumonia. For these methods to work effectively, there must be proper training, suitable equipment, and clearly defined protocols. Incorporating NIPPV into emergency medical services can greatly improve patient outcomes and relieve pressure on hospital’s emergency departments.
