Respiratory Therapy 101: Just Keep Breathing

As part of my ongoing effort to be responsive to reader input in the form of comments and search-engine hits, I’m going to blather a bit about EMS and CPAP. Anyone who needs acronym definitions, I’ll put them at the bottom of the post. Sorry to “talk shop” so much lately, but I’ll resume the stories at some point soon.
Our Lady of Immaculate Grace is a fairly rural hospital as you may have picked up. We serve a large rural area in conjunction with a couple of smaller community hospitals and one hospital that is larger than us and handles the major trauma. Because of the rural nature of this area, we tend to get a lot of patients who have a prolonged transport time: that is to say, by the time the patient is reached either by rural volunteer EMS or by Backwoods Ambulance, there has been an extensive amount of time chewed out of the “Golden Hour.”

In some cases (such as the all-too-common ETOH-induced “FDGB” cases) the Golden Hour isn’t much of a concern, because the basic medical needs can be met satisfactorily by a paramedic in the field. But in some cases, specifically a lot of respiratory cases, the Paramedics have limited options: intubate or give oxygen. This leaves out a crucial middle step that we often use in house, which is non-invasive positive pressure therapy such as CPAP or BiPAP.

The advantages to non-invasive positive pressure ventilation (NIPPV) or related modalities like CPAP and BiPAP is that they can effectively treat the patients pulmonary malfunctions without the risks of endotracheal intubation. For many older patients with certain permutations of COPD, endotracheal intubation can be the beginning of the end. Being intubated itself is risky because of the amount of sedation required to intubate someone, plus the possibilities of airway or oral damage. It’s rare but it happens. Another risk of being intubated is the potential for infection, and while Ventilator-Associated Pneumonia is on the decline because of a number of new initiatives, it still happens. Finally, many patients who wind up intubated in the field or in the ER become these sort of chronically-ventilated trainwrecks who are difficult or impossible to wean off the ventilator without an extremely aggressive pulmonary staff, something that a lot of hospitals have but which Our Lady and many smaller hospitals lack.

The solution to these problems has become NIPPV, specifically in the form of CPAP or BiPAP. In the ER at Our Lady, we use CPAP and BiPAP fairly consistently with patients who are in respiratory failure or who are headed in that direction with massive success. Many times I have seen patients make a 180-degree turnaround with little more than CPAP and some Lasix, or BiPAP coupled with the standard treatment for COPD exacerbations.

The problem with NIPPV, especially in rural areas like this one (I actually have to carve these blogs on sheets of granite and give the sheets to sherpas to carry into a city with the internet…e-mail involves smoke signals and morse-coded rifle shots) is that by the time the patient reaches the ER, the window of opportunity where NIPPV would have worked is shut and the patient is either dead or intubated. To solve that problem, Backwoods EMS has been trying out a new form of in-field CPAP that uses low-flow oxygen and some sort of pressure device that I don’t fully understand to generate up to 15 cmH2O of CPAP in the back of the ambulance. I can’t tell you how many patients this has saved from the ET tube.

To give one example, EMS recently brought us a CHF patient from about forty miles away, which is a long and tiresome ambulance ride. The paramedics can do a lot to treat CHF: I believe that they can give Lasix around here, and that in addition to some good CPAP is usually all it takes to treat an episode of CHF. Now, before Backwoods was given their CPAP equipment, this patient would have come to us intubated and spent a long time in ICU being “weaned” from the ventilator and developing complications. But because of their newfangled CPAP-in-the-truck equipment, this patient came in the soor breathing easily without a huge tube in their trachea. The patient stayed for a day on the stepdown unit and was discharged to home faster and more safely than if she had been intubated in the field.

In conclusion, it’s my personal opinion that all ALS trucks should be equipped with CPAP. It’s a wonderful treatment for so many things: CHF, COPD exacerbations, and mild respiratory failure jump immediately into my mind. The fact is that CPAP can do all that plus keep patients off the tube, and sometimes that’s enough to save a life in itself.

Acronyms:

ETOH: med-speak for “Alcohol.”

FDGB: fall down go boom

CPAP: Continuous Positive Airway Pressure

BiPAP: Bilevel positive Airway Pressure

COPD: Chronic Obstructive Pulmonary Disease, such as emphysema or chronic bronchitis