Prehospital High Flow Oxygen Increases Risk of Death

[RNEMT26 40]

Medscape has an excellent article on the same topic that I believe references the same work. [Jan, 2011]

Chronic Obstructive Pulmonary Disease and Emphysema in Emergency Medicine

http://emedicine.medscape.com/article/807143-overview#a0104

Among other things, it serves to remind us that COPD is a basket of comorbidities. Do knowlegable people out there have experience with CPAP/BiPAP with respect to bronchitis vs emphysema?

At present, HVREMAC allows for CPAP in COPD, but WREMAC does not. Obviously different physicians have different opinions as to the value of CPAP for COPDers. Is it perhaps more effective with one type of COPD?

I also think a take home message is that before intubating the conscious patient, or letting that patient deteriorate that CPAP is worth a try. Worst case, we take it off, correct?

I have not seen may people need CPAP/BiPAP for bronchitis. Of course there are exceptions to everything and people have gone into resp. fail and required intubation, strangely enough those patients usually have COPD but it's usually comlicated by Pneumonia and sepsis.

IMO, CPAP is ok. COPDers have BOTH Chronic Bronchitis AND Emphysema. Now there are other forms of COPD- Bronchiectasis and CF, but for simplicity sake and reality sake I think most of what we see and treat in the field is the regular COPD and by that I mean Chronic Bronch. and emphysema. Im sure maybe someone working in NYC or another major metro area may have seen the other diseases I mentioned but out in the suburbs I highly doubt it. Either way you slice it, CPAP gonna increase oxygenation, but you gotta make sure they can get the air out too. BiPAP attempts to do that, with 2 levels of pressure, 1 to help the air in, and a lower one to 'help' the air out. PTs with Emphysema 'air trap' which leads to increases in CO2 and eventually leads to Resp. acidosis and a host of other problems, which is why they tend to have a 'barrel chest' if you've ever noticed.

People with Bronchiectasis produce large amounts of sputum daily, almost 250cc. And the same goes with people with Cystic fibrosis, hence why these are termed 'obstructive pulmonary diseases' the major problem with them is the 'obstruction' on the bronchi and smaller air passages with sputum/phlegm etc. So if CPAP is all you got then you use what you have and make due. It will help with oxygenation, but what they need the most is to clear their airways. Which is why some of the CF PTs wear chest percussion vests to help with that.

[MoFire390 118]

It depends on the situation. Im not sure of how much you know about BiPAP/CPAP but it has obviously 2 settings a IPAP (inspiratory) and an EPAP (expiratory). Usually we set it @ 10/5 with most patients and tweak it as necessary. The EPAP is lower and is supposed to help with exhalation. CPAP it just what it says Continuous Positive Airway PRessure, so a COPDers have a problem with air trapping, so it's getting their out not, not necessairly getting it in.

Now if it's somone who is in resp. failure then chances are this person is gonna get intubated at some point, which in all honesty is sometimes the best thing for them. We usually rest their lungs for 2-3 days and then wake them up and pull that tube. If the situation is more in the CHF realm then you can us BiPAP or CPAP with diuretics and nitrates (sometimes) to help clear their lungs up.

thank you...ive only seen cpap used once. pt had history of copd and low O2 sats. by the time i arrived on scene the medic had it on the pt and we were getting ready to txp to the hospital. kind looks like a NRB mask on steroids.

[ckroll 101]

I have not seen may people need CPAP/BiPAP for bronchitis. Of course there are exceptions to everything and people have gone into resp. fail and required intubation, strangely enough those patients usually have COPD but it's usually comlicated by Pneumonia and sepsis.

IMO, CPAP is ok. COPDers have BOTH Chronic Bronchitis AND Emphysema. Now there are other forms of COPD- Bronchiectasis and CF, but for simplicity sake and reality sake I think most of what we see and treat in the field is the regular COPD and by that I mean Chronic Bronch. and emphysema. Im sure maybe someone working in NYC or another major metro area may have seen the other diseases I mentioned but out in the suburbs I highly doubt it. Either way you slice it, CPAP gonna increase oxygenation, but you gotta make sure they can get the air out too. BiPAP attempts to do that, with 2 levels of pressure, 1 to help the air in, and a lower one to 'help' the air out. PTs with Emphysema 'air trap' which leads to increases in CO2 and eventually leads to Resp. acidosis and a host of other problems, which is why they tend to have a 'barrel chest' if you've ever noticed.

People with Bronchiectasis produce large amounts of sputum daily, almost 250cc. And the same goes with people with Cystic fibrosis, hence why these are termed 'obstructive pulmonary diseases' the major problem with them is the 'obstruction' on the bronchi and smaller air passages with sputum/phlegm etc. So if CPAP is all you got then you use what you have and make due. It will help with oxygenation, but what they need the most is to clear their airways. Which is why some of the CF PTs wear chest percussion vests to help with that.

Interesting, and thanks for the reply. Learned literature seems to be making a distinction between COPD primarily as upper airway inflammation a.k.a. pink puffers and primarily emphysemic, those with compromise of the alveoli, a.k.a. blue bloaters. Obviously with a range in between.

From a pre hospital perspective it used to be a distinction without a difference in that we treated it similarly. Now that CPAP is available, we may have a treatment option that will affect these mechanisms differently....or maybe not.

I'm reading here that air trappers may benefit from BiPAP, not necessarily CPAP. Per literature, CPAP functions by holding open airways, increasing pressure in the alveoli and moving fluid back across the membrane, and decreasing the work of breathing. What puzzles me is what is happening physiologically. People primarily with upper airway obstruction may respond differently to CPAP than those with damaged alveoli and dead space.

My mental model of events is that we are trying to increase ventilation, not oxygenation insomuch as O2 deranges blood chemistry and decreasing CO2 corrects that. Different causes of COPD will both have ventilation/perfusion mismatch, but perhaps for very different reasons. I'm not clear on what is happening in the pt.

[vtach39680 23]

I would like to first say that i agree that you need to provide good clinical care for patients. I think if you look at the history of the part 800 equipment list in o2 therapy over the last 15 years the push to go to 100% high flow O2 has to do with lack of training / understanding of what is going on with the patient. ( to much I see this I do this).

I have only been involved in EMS since the early 90's so i will not make comment on training earlier then that. In the 90's we had simple (rebreathing) mask, venturi masks (colored plugs able to deliver different concentrations of O2) non-rebreathing face masks, and nasal cannulas. and the great demand valve mask.

O2 administration for non-rebreathing face mask used to be litter flow should be adjusted to keep bag inflated during patient respirations. too often then not people did not pay close enough attention to the patients respiratory status and the bag would not be filled thus not providing any O2 to the patient. Protocol change made to make it 10LPM same above problem occurred protocol change made to 12 and so her we are with cookie cutter mindset to protect the most amount of patients that are out there with minimal harm to the small percentage of patients that would be adverse.

nothing will change till we will only accept good clinical judgment and retrain or purge those who can not provide it

[RNEMT26 40]

I would like to first say that i agree that you need to provide good clinical care for patients. I think if you look at the history of the part 800 equipment list in o2 therapy over the last 15 years the push to go to 100% high flow O2 has to do with lack of training / understanding of what is going on with the patient. ( to much I see this I do this).

I have only been involved in EMS since the early 90's so i will not make comment on training earlier then that. In the 90's we had simple (rebreathing) mask, venturi masks (colored plugs able to deliver different concentrations of O2) non-rebreathing face masks, and nasal cannulas. and the great demand valve mask.

O2 administration for non-rebreathing face mask used to be litter flow should be adjusted to keep bag inflated during patient respirations. too often then not people did not pay close enough attention to the patients respiratory status and the bag would not be filled thus not providing any O2 to the patient. Protocol change made to make it 10LPM same above problem occurred protocol change made to 12 and so her we are with cookie cutter mindset to protect the most amount of patients that are out there with minimal harm to the small percentage of patients that would be adverse.

nothing will change till we will only accept good clinical judgment and retrain or purge those who can not provide it

I totally agree and that's what I was saying before and some people got their undies in a bundle about it. Unfortunately some EMS workers fail to understand the 'why' part of what we are doing, or trying to accomplish. And people just do things and their excuse is "because it's protocol' right, however in every protocol ive ever worked with in the hospital or anywhere, here is usually a little caveat that says it's not written in stone and that the protocol is no substitute for good clinical judgement. Unfortunately some people dont get that.

Edited July 19, 2011 by RNEMT26

[JohnnyOV 2]

I totally agree and that's what I was saying before and some people got their undies in a bundle about it. Unfortunately some EMS workers fail to understand the 'why' part of what we are doing, or trying to accomplish. And people just do things and their excuse is "because it's protocol' right, however in every protocol ive ever worked with in the hospital or anywhere, here is usually a little caveat that says it's not written in stone and that the protocol is no substitute for good clinical judgement. Unfortunately some people dont get that.

The biggest problem, is that this school of thought is not taught in EMT-B class. You're given a protocol, told to memorize it, given a practical exam on it to make sure you can properly hook a hose line to the nipple on the O2 bottle, and then sent to "save lives." I think a program that is double in length, or even 1.5 times as long, would allow the instructors time to teach "good clinical judgement." If you have no idea about the hows and whys of something occurring, how can you possibly treat it correctly?

Edited July 19, 2011 by JohnnyOV