Cpap?

[EMTstaroflife]

I had a pt that was having an asthma attack and have been having mild sympotoms for three days, when she finially called EMS because her friends were smoking around her in an enclosed trailer.:wacko: When I listened to her LS in the house they were wheezy. When we loaded her up in unit and place NRB on her, LS were Wheezy. When I gave her an albuterol jetneb treatment, LS were wheezy. Then because I felt she was getting fatigued but was still able to maintain patent airway, I opted for the CPAP. However, to my surprise, I was having difficult ascultating her LS. Is this normal? Of course, by now my crew and I are already enroute to the hospital and I realize that there is extra noise surrounding me that wasnt there when we were in the residence. My question was are you supposed to be able to hear LS if the pt is moving air while on CPAP? I wasn't sure and my pt was becoming more tired. I was concerned that she might just stop breathing all together, so I stepped it up to C3 and continued to talked to the patient about focusing on her breathing. Once we were at the hospital and pt was transfered I listened to her LS again, wheezing in all fields(however there was improvement from field assessment). Thanks for all your assistance.

 

[MrBrown]

This is a perfect question for VentMedic but I'm going to go out on a limb (or more appropriately a bronchial tree) here and say that I don't think CPAP is beneficial for asthma.

Asthma is mucousal edema and bronchoconstriction or bronchospasm; wheres the traditional uses for CPAP has been to keep alveoli from collapsing due to bonding of the hydrophillic surfactant to fluid in the alveoli e.g. cardiogenic edema.

Not sure it's going to do a lot; my money is cautiously on adrenaline and salbutamol plus whatever steriods you carry or magnesium

Did you nebulise salbutamol through the CPAP setup (if you can even do that?)

 

[46Young]

We'll need a better Hx other than she was "wheezy". You're being too vague, and leaving out most of your assessment. No mention of mental status, in what lung fields you heard wheezing, ECG/12 lead, temp, pulse ox, skin CTC, self-medication PTA of EMS and any perceived benefit from the pt, change in pt positioning/preservation of mental status/other improvements (or lack thereof) after CPAP admin.

Did you consider an in line neb? A mag drip? Solumedrol? Atrovent? IM/SQ epi if severe bronchoconstriction and questionable delivery of aerosolized meds? IV epi if hypotensive and questionable IM absorption? Did you R/O all other potential causes of bronchoconstriction before deciding on your Tx?

Anyway, if I had difficulty in auscultating L/S, I would look at other signs such as asking my pt if the CPAP is helping (while observing a greater ease in speaking or not), changes in SPO2, skin, mental status such as combativeness or lethargy. If the pt is getting tighter, you should start thinking about epi and maybe dropping a tube down the line if that doesn't work. Always try to stay ahead of your pt and save them a tube. Did this pt have a line? If the pt is presenting with increased lethargy and/or fatigue in respiration, you need to get to work.

 

[EMTstaroflife]

We'll need a better Hx other than she was "wheezy". You're being too vague, and leaving out most of your assessment. No mention of mental status, in what lung fields you heard wheezing, ECG/12 lead, temp, pulse ox, skin CTC, self-medication PTA of EMS and any perceived benefit from the pt, change in pt positioning/preservation of mental status/other improvements (or lack thereof) after CPAP admin.

Did you consider an in line neb? A mag drip? Solumedrol? Atrovent? IM/SQ epi if severe bronchoconstriction and questionable delivery of aerosolized meds? IV epi if hypotensive and questionable IM absorption? Did you R/O all other potential causes of bronchoconstriction before deciding on your Tx?

Anyway, if I had difficulty in auscultating L/S, I would look at other signs such as asking my pt if the CPAP is helping (while observing a greater ease in speaking or not), changes in SPO2, skin, mental status such as combativeness or lethargy. If the pt is getting tighter, you should start thinking about epi and maybe dropping a tube down the line if that doesn't work. Always try to stay ahead of your pt and save them a tube. Did this pt have a line? If the pt is presenting with increased lethargy and/or fatigue in respiration, you need to get to work.

The reason for the poor hx was because my question wasn't really pt realated, I was inquiring about given the best scenerio if u "should" be able to hear LS while wearing the CPAP? I'll be in contact with my training officer also in reference to the specific CPAP our service carries.

In response to the above questions, yes I did ask the pt if it was helping, I was proactive in getting a line, doing a ECG tracing-sinus tach, her mentation was changing, we carriy solumedrol as a steriod in addition to SQ epi. I wasn't exactly sure so I erred on the side of the pt and "assumed" that she was beginging to clamp down...to my relief as we were arriving at the ED. That's for ur attentiveness and prompt responses.

 

[VentMedic]

The reason for the poor hx was because my question wasn't really pt realated, I was inquiring about given the best scenerio if u "should" be able to hear LS while wearing the CPAP? I'll be in contact with my training officer also in reference to the specific CPAP our service carries.

Every patient will present differently and every CPAP device will give different results. Some CPAP devices are little more than a O2 mask with a resistive valve.

Each patient will also be different depending on whether the bronchospasm has decreased ventilation or if the CPAP has distended the FRC to where air movement is decreased and air trapping is more pronounced. This situation can lead to increased work of breathing and hemodynamic compromise. For others, a little CPAP might help splint the airways to improve air movement. CPAP may also create turbulent flow with ineffective medication delivery and breathing patterns. This can be from improper device flow delivery for either too little or too much flow. The patient's inspiratory demand might be high or their fatique might be enhanced breathing against a resistive valve. There are reasons why hospitals spend several thousand dollars on their CPAP and BiPAP(trade name) devices.

Of course, this is just discussing the "asthma" patient and one that has not developed all the chronic cardiac conditions that affect how effective a CPAP device will be.

 

[MrBrown]

I erred on the side of the pt and "assumed" that she was beginging to clamp down...to my relief as we were arriving at the ED.

Meaning you did .... what exactly?

From your story you have a moderate asthmatic who appears to be getting worse and it seems you gave her one round of salbutamol.

Is asthma an indication for CPAP in your standing orders?

What did her condition look like when you turned up vs during your use of CPAP? Words per breath? evidence of cyanosis? SPO2? Work of breathing? Mental status/GCS? Chest movement? Heart rate? Lung sounds are but one indicator.

Did you give her any more salbutamol through the CPAP setup?

If your asthma patient is not wheezing, is that a good thing?

 

[redcrossemt]

Sounds like additional albuterol and/or epinephrine was indicated in this patient instead of, or at least before, CPAP. CPAP, as described above, can add to the air trapping in some asthma patients, causing decreased air movement which is quickly and severely detrimental to the patient. I doubt CPAP is indicated in your protocol for asthma, as it's a dangerous thing for these patients if you don't have the physiological knowledge to support it.

If you had decided to do a trial of CPAP, it would be important to continue with pharmacological interventions as well... including the albuterol, epinephrine, solumedrol, and perhaps magnesium, etc... because CPAP will only be a short-term solution for this patient. BiPap would be more useful, but again, only a short-term solution, and important to use with drug interventions as well.

If the lung sounds were truly diminished from arrival, it could be due to a natural progression of things (fatigue, air trapping, etc.) or from your CPAP making things worse by the same methods.

And, if the patient's mentation was headed in the wrong direction after applying CPAP, I'd remove it and see if anything changed. Also, history of asthma, wheezing, worsening condition, decreased mental status => give the epi!!!

I would also question the amount of oxygen being supplied in your CPAP. Our units don't provide much more than room air. This patient would have likely benefited from additional oxygen in the small amount of air exchange she did have.

 

[MrBrown]

I don't think CPAP was the best choice here

 

[Shishkabob]

I'd have to disagree that CPAP is not indicated, as I just used it last night on a severe asthma patient with FANTASTIC results.

She was satting 80%, refractive to her 2 albuterol, my 2 albuterol and my atrovent treatments. My protocols allow CPAP for wheezing, both cardiac and non-cardiac in origin. I was going to give CPAP a try before doing SQ Epi. It REALLY made a difference.

 

[VentMedic]

I'd have to disagree that CPAP is not indicated, as I just used it last night on a severe asthma patient with FANTASTIC results.

She was satting 80%, refractive to her 2 albuterol, my 2 albuterol and my atrovent treatments. My protocols allow CPAP for wheezing, both cardiac and non-cardiac in origin. I was going to give CPAP a try before doing SQ Epi. It REALLY made a difference.

It is difficult to make a broad statement for asthma or COPD since each patient will have different lung function and be in different stages of their disease process where lung remodeling has occurred. It will also depend on their inflammatory process, FRC and secretions as to how well they will tolerate just CPAP. One would need to be very cautious and monitor their hemodynamic status which can be compromised. BP may need to be supported if the lungs become hyperinflated to the point where pressors may need to be started or fluids given which again would also depend on the degree of cardiac involvement.

Work of breathing would also have to be accessed if the patient is tiring and you only have CPAP and not a Bilevel device to offer supported breaths. Some patients can fatique easily with the resistance of the valve.

These patients will challenge your assessment skills and knowledge of the disease processes. No blanket statement should ever be made that it is FANTASTIC for all patients. Assess, evaluate and expect complications while hoping for good outcomes.

 

[MrBrown]

No blanket statement should ever be made that it is FANTASTIC for all patients

I am fantastic for all my patients ^_^ (I know its bad to lie....)

The one service here that does use CPAP does not use it for asthma; I have never seen an asthmatic with CPAP nor heard of its use for asthma outside North America it seems.

Now, I venture a guess here only (.... it's just too early in the a.m. for respiratory pressures) but could CPAP for asthma potentially be harmful if they can't exhale (as effectively) and we are contioniously increasing the pressure inside the lungs? Sounds like big bag hyperinflaton waiting to happen.

 

[Shishkabob]

Never said it was FANTASTIC for all patients. I weighed my options, I decided to go least invasive, gauged her reaction to it, and she tolerated it well with good results, so it made me happy for the time I had her.


Had OLMC agreement to give it a try anyhow, so it's like like I was working unilaterally

 

[TraprMike]

B)I would of just rolled a window down to give her some fresh air..

 

[VentMedic]

I would of just rolled a window down to give her some fresh air..

As an EMT-B, do you have any other options for the treatment of an asthmatic that you might consider? Fresh air is good since many asthmatics and COPD patients often feel like they are suffocating and often require a fan in their room to alleviate that feeling.

 

[MrBrown]

B)I would of just rolled a window down to give her some fresh air..

Heck let's try some chicken soup too, perhaps this is a job for Jack Armstrong the All American Ambo

 

[vquintessence]

As an EMT-B, do you have any other options for the treatment of an asthmatic that you might consider? Fresh air is good since many asthmatics and COPD patients often feel like they are suffocating and often require a fan in their room to alleviate that feeling.

Absolutely. How many of you out there have had to transport somebody (transfer or emergent) with their fan blowing all the while?

It's amazing how some partners and other health professionals will act like you've lost your mind, or imply it's less than psychosomatic.

 

[hreeves877]

I'd have to disagree that CPAP is not indicated, as I just used it last night on a severe asthma patient with FANTASTIC results.

She was satting 80%, refractive to her 2 albuterol, my 2 albuterol and my atrovent treatments. My protocols allow CPAP for wheezing, both cardiac and non-cardiac in origin. I was going to give CPAP a try before doing SQ Epi. It REALLY made a difference.

The difference with this situation and the original post is that you followed here two rounds of albuterol with another 2, plus atrovent. It seems to me that the original patient probably could have benefited from another treatment before CPAP was considered as an option. Everywhere is different, but where I'm from, we use CPAP mostly on end stage CHFers as a 2 part tx with Lasix. As has been said, every patient, as well as every dept is different, but I personally have never seen or heard of CPAP being used on an asthma patient. As a last resort, I can see it being an option, but after only one breathing treatment? Eh, not too sure about that one.

 

[EMTstaroflife]

Thanks for all your all ur support! great discussions!