Continuous Positive Airway Pressure

(CPAP)

“Not being limited to what’s inside the box”

11300 - 49th Street North

Clearwater, Florida 33762-4807
727-573-0088 / 800-237-6418

©
2014 Mercury Medical.® All rights reserved
Table of Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

How CPAP Works . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Properly Applied CPAP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Understanding the Importance of Flow Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

What Types of Patients Are Not Candidates for CPAP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

CPAP and CHF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

CPAP and COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

CPAP and Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

CPAP and Pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
CPAP and Near Drowning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
CPAP and Pulmonary Embolism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

CPAP and DNR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

CPAP and Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
CPAP and Tracheostomy Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

When Should CPAP Be Discontinued and Manual Ventilation Started . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Other Factors to Consider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

CPAP is Cost-Effective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10,11

©Mercury Medical 01/2014 ML2014-263 Rev.A

1.
Introduction:

CPAP therapy has been utilized in medicine for over 100 years. However, the use of CPAP in EMS is comparatively
new and is not a standard of care in every system.

The introduction of CPAP to EMS ranks near the top as one of the most effective treatments introduced to the
pre-hospital environment in the last fifteen years. With that said, some EMS systems have limited the use of CPAP
to congestive heart failure (CHF) or for adults only; when, in fact, any patient in respiratory distress should be
considered a candidate for CPAP. The goal of CPAP is to reduce the work-of-breathing and buy time for more
definitive treatments to work.

The premise of this booklet is to inform EMS clinicians on the expanded use of CPAP. Only through education
and experience can we improve in the medical specialty of Emergency Medicine.

Ignorance is defined as,

“The condition of being uneducated, unaware, or uninformed.”

Merriam-Webster Dictionary

“Knowledge is of no value unless you put it into practice.”

Dr. Anton Chekhov

Physician/Playwright 1860 – 1904

Disclaimer: Although the information and recommendations set forth herein (hereinafter referred to as "Information") are
presented in good faith and believed to be correct as of the date of this writing, Mercury Medical® makes no representations as to
the completeness or accuracy thereof. Information is supplied upon the condition that the persons receiving it will make their own
determination as to its suitability for their purposes prior to use. In no event will Mercury Medical be responsible for damages of
any nature, whatsoever, resulting from the use of or reliance upon the statements within this booklet.

2.
How CPAP Works:

Continuous Positive Airway Pressure, (CPAP), is the maintenance of positive pressure throughout the complete
respiratory cycle, (inspiration and expiration), when breathing spontaneously. CPAP is not the same as Positive
End Expiratory Pressure or PEEP. PEEP only provides pressure on the expiratory side by offering resistance to
exhalation using a spring-loaded valve or air flow. If a device only provides PEEP, then by definition, it is an
oxygen administration device with a PEEP valve, not CPAP. The best way to determine if a device truly provides
CPAP is to have a pressure manometer in-line. Having a pressure manometer in-line should be mandatory for
determining pressure administered, patient safety and documentation. CPAP is measured in centimeters of water,
written as cmH2O.

Properly Applied CPAP:

1. During the inspiratory phase, patients in distress will have to create a higher flow rate of air to meet their needs,
this will present as an increase in work-of-breathing (WOB). Patients in respiratory distress may need to achieve
inspiratory flow rates greater than 65 liters per min (LPM). With the inspiratory support of CPAP, the patient
does not have to work as hard to inhale and overcoming the auto PEEP in the lung. Auto-PEEP represents the
abnormal, and usually undetected, residual pressure above atmospheric remaining in the alveoli at end-exhalation
due to air trapping. Auto-PEEP is also referred to as occult PEEP, intrinsic PEEP or dynamic hyperinflation. The
auto PEEP has to be overcome each time a person inhales, for a healthy person the work is minimal and goes
unnoticed. However, those patients with stiff lungs, (CHF and Pulmonary Fibrosis), have to work extremely hard
to overcome the increased auto PEEP on every breath.

2. The increased inspiratory pressure also increases the size, therefore the surface area of the alveoli, providing a
greater opportunity for gas exchange or respiration. The process increases the Functional Residual Capacity (FRC)
of the lung. The FRC is the area where gas exchange takes place.

3. Since a greater oxygen percentage is able to reach the alveoli during CPAP, the partial pressure of the oxygen
molecule will be greater. The higher partial pressure will allow more oxygen to diffuse into the blood stream
improving oxygenation. Oxygen under pressure should be considered oxygen therapy in its most efficient form.
Increased oxygenation could result in lowered cardiac work and oxygen consumption with a reduced cardiac
arrhythmia risk.

4. Fluid in the alveolar space cannot only make the lung stiff, (increasing inspiratory work-of-breathing), it also
creates a barrier that can reduce gas exchange. The pressure from CPAP can reduce the fluid by forcing fluid out
of the alveolar space back into the interstitium.

5. During the expiratory phase, the patient will breathe against a threshold of resistance that works as a pneumatic
splint to hold the airways open. Patients with chronic lung disease have weakened airways that have a tendency to
collapse on expiration, causing air trapping. Having the airways stinted open during exhalation will make inspiration
on the next breath less difficult.

6. The resistance during exhalation can open non-ventilated areas of the lung recruiting alveoli that have collapsed
due to atelectasis, (a collapse of lung tissue affecting part, or all, of one lung effecting gas exchange).

7. CPAP decreases pre-load and after-load on the heart reducing the heart’s workload. However, a reduction in
pre-load and after-load will have an effect on the patient’s blood pressure. Patients should have a systolic blood
pressure of at least 100 mmHg before starting CPAP.
3.
Understanding The Importance of Flow Rates:

“Flow rates have to match the patient’s need or CPAP will fail.”

The flow rate or velocity of the air/oxygen a patient breathes in has a great impact on their work-of-breathing.
Most everyone has experienced the sensation of shortness-of-breath at some point. For example, anyone who has
worn an SCBA, (Self-Contained Breathing Apparatus), while doing strenuous work most likely felt some shortness-
of-breath, some may have opened the bypass valve to get more air. Those that have opened the bypass did not
need more air, they needed it faster, to meet the demand caused by the extra work. This can also happen by simply
putting on an N95 mask. The filter on the N95 mask takes extra work to inhale. For a healthy person, this extra
work caused by the mask or the SCBA generally goes unnoticed.

For patients having difficulty breathing, the velocity of the air/oxygen is also of great importance. Patients in
respiratory distress will have to work harder to get the air at the speed they need it and will exhibit difficulty
breathing and a complaint of shortness-of-breath. Once the work-of-breathing exceeds the patient’s capability to
meet that need, the patient will go into respiratory failure. Patients in respiratory failure are NOT candidates for
CPAP, they need manual ventilation or a ventilator.

Most CPAP devices provide the velocity by one of two methods. The device either attaches to the high pressure
side of the regulator or flowmeter, (approximately 140 LPM), or they attach to the low pressure side and use
Bernoulli's Principle to increase the speed, (approximately 120 LPM), either method has been found to be effective.
If the flow rate does not meet the patents need, they will experience air hunger and will fight the treatment. Some
clinicians advocate sedating patients who fight CPAP therapy, in most cases that would be counterproductive and
may lead to respiratory depression. However, that does not mean the patient cannot be given an anti-anxiety
medication. The first step to consider when a patient is non-compliant with CPAP is to increase the flow rate, even
if it increases the pressure. Some devices are at the maximum flow rate at all times, (attached to the high pressure
side), others increase the flow rate as the pressure is adjusted up, (attached to the low pressure side).

Bernoulli's Principle – As the flow is narrowed, the velocity will increase. This can be demonstrated by putting your
finger over the end of a garden hose causing the water to shoot farther and faster. The maneuver does not increase
the volume, just the forward velocity.

What Types of Patients Are NOT Candidates for CPAP?

Being able to assess and determine who is, and who is not, a candidate for CPAP has a great impact on whether
CPAP will be effective or not. CPAP can be a very effective treatment for patients in respiratory distress but is
not indicated for patients in respiratory failure. Respiratory distress patients are still compensating even though
they may be working hard. It is not uncommon for respiratory distress patients to have oxygen saturations (SpO2 )
and carbon dioxide, (CO2), levels within normal range. Key determinants include; is the patient alert, (even though
they are working hard), and can they follow directions. Patients that have gone into respiratory failure may exhibit
a decrease in work-of-breathing, CO2 levels climbing, oxygen saturations falling, and their level of consciousness
declining, (most likely from CO2 narcosis). CPAP is not indicated for respiratory failure patients. All respiratory
distress patients, regardless of the underlying pathology, should be considered a candidate for CPAP. Some EMS
systems limit their use of CPAP to Congestive Heart Failure patients, a trend that is changing as EMS systems
become more comfortable and more educated on the therapy.

4.
CPAP and Congestive Heart Failure (CHF):

The treatment of Congestive Heart Failure, (CHF), by EMS has changed significantly in the last couple of years.
The mainstays of CHF in the pre-hospital setting are CPAP and nitroglycerin. The efficacy of Lasix and Morphine
is under scrutiny and has been removed from many EMS protocols. Many systems that adopt CPAP start with
CHF. The effects of CPAP are well suited for the physiologic issues associated with this disease. Pulmonary
edema, associated with CHF, makes the lungs stiff and it is difficult for the patient to inhale; and can be observed
as difficulty breathing during the inspiratory phase of ventilation or inspiratory shortness-of-breath. Since CHF is
primarily a heart problem, CPAP addresses the side effects of a failing heart and its impact on the lungs. For
example, pulmonary edema can cause what is called, a ventilation/perfusion mismatch often called a V/Q
mismatch. What this means is anytime there is a barrier that prevents the oxygen from getting to the blood, there is
a mismatch, in this case the fluid is the barrier. CHF is a process that will continue to spiral down the cardiogenic
shock pathway until the cycle is broken. As the patient’s heart fails, more fluid ends up in the lungs. With more
fluid in the lungs, less oxygen makes it to the heart muscle, so the heart fails even more. The first step in stopping
the cycle is the early use of CPAP and nitroglycerin. If the patient does not have lung disease then the airways
should function normally and not collapse on exhalation. In this case, the inspiratory pressure will force the fluid
out of the lungs, expand the alveoli which, in turn, will increase gas exchange (respirations) improving oxygenation.
In addition, with the airways being held open by the expiratory resistance, the patient does not have to overcome
the auto PEEP at the beginning of each breath. With the improvement of gas exchange and reduced impact of
auto PEEP, the patient’s work-of-breathing will be reduced. With the reduced work, there will be less stress on the
heart.

A key factor in the initiation of CPAP, as well as nitroglycerin, is the patient’s blood pressure. It is recommended
that the systolic blood pressure be at least 100 mmHg before starting CPAP or nitroglycerin, due to the reduction
in pre-load and after-load.

CPAP and Chronic Obstructive Pulmonary Disease (COPD):

COPD is characterized by two different disease processes, emphysema and chronic bronchitis. COPD damages the
airways causing them to decrease in size or collapse on expiration. According to Poiseuille's Law, a reduction in the
diameter by ½ will increase the work-of-breathing by a multiple of four, causing most COPD patients to exhibit
expiratory difficulty breathing or expiratory shortness-of-breath. Chronic lung patients also trap air because of the
collapsed airways making it difficult to exhale as well as inhale. In chronic bronchitis, the airways become swollen
and there is an increase in mucus production, both of which can narrow the airway. A good way to feel what it’s
like to have COPD is to take a deep breath and hold it, then do all of your breathing on top of the deep breath.
CPAP can be very successful in the treatment of COPD. By stinting the airways open, the patient can exhale easier
and more completely, resulting in less work. Since the airways, and not the alveoli, are the problem COPD patients
are often treated with nebulizer treatments with bronchodilators. Since CPAP holds the airways open, breathing
treatments are more effective at depositing the medications deeper in the lungs. Using continuous nebulization has
been shown to be more effective than repeated treatments.

5.
CPAP and Asthma:

Asthma is characterized by a triad of problems; bronchospasm, airway swelling, and increased mucus production.
Due to the narrowing of the airway especially during exhalation by these problems, asthmatic patients will exhibit
expiratory difficulty breathing. It has been shown that if bronchospasm and airway swelling are successfully treated,
the patient can deal with the increased mucus production. Before CPAP was introduced to EMS, asthma was treated
with bronchodilators, (Albuterol and Atrovent), for the bronchospasms and steroids, (Solu-Medrol) IV, for airway
swelling. Bronchodilators and steroids are still the first-line standard of care for asthma.

CPAP can also be used in conjunction with bronchodilators and steroids in the treatment of asthma. Since
asthmatics have trouble getting the air out, using CPAP to stint the airways open, will facilitate exhalation, (reducing
air trapping), and reduce the work-of-breathing. CPAP will also make nebulizer treatments more effective by
allowing deeper penetration of the medication.

CPAP and Pneumonia:

Pre-hospital treatment of pneumonia is supportive in nature. Historically treatment has been directed toward
oxygenation and fluids to prevent dehydration. CPAP does not treat pneumonia directly, however it can reduce
the work-of-breathing often seen with pneumonia. Pneumonia, in most cases, is found unilaterally, (on one side),
and can interfere with gas exchange, (respiration), on the effected side. Remember, there may be additional areas
of the lung that could be ventilated by using CPAP to recruit unventilated alveoli. The goal is to offset what the
pneumonia is blocking with recruited alveoli or open small airways previously obstructed.

CPAP and Near Drowning:

Near drowning is the term for survival after suffocation caused by submersion in water or another fluid as
compared to drowning where the patient is dead. CPAP is not the same as a Bag-Valve-Mask and is contraindicated
for patients that are apneic or in cardiac arrest. Full face mask CPAP has been used with great success, in the
hospital setting, for many years to avoid intubation of patients suffering from Acute Respiratory Distress secondary
to near drowning. Some near drowning victims may go on to develop non-cardiogenic pulmonary edema making
CPAP a viable option. Near drowning patients may also have significant hypoxia and bronchospasm, both of which
can be effectively treated with CPAP. With the positive effects of CPAP on non-cardiac pulmonary edema. hypoxia,
bronchospasm, along with the potential recruitment of non-ventilated alveoli, the work-of-breathing can be greatly
reduced by CPAP, potentially preventing intubation.

CPAP and Pulmonary Embolism (PE):

Historically EMS has been limited to general supportive care and high flow oxygen for the treatment of pulmonary
embolism. If a patient is suspected of having a pulmonary embolism and their systolic blood pressure is above
100 mmHg, CPAP may be effective in reducing the work-of-breathing. CPAP can help correct hypoxia from a PE
by recruiting alveoli that are still being perfused but may not be ventilated. In addition, since CPAP increases the
surface area of the alveoli with a higher FiO2, (more partial pressure from the oxygen molecule), more gas exchange
can take place. CPAP is contraindicated in patients with a low blood pressure since the positive pressure can reduce
the pre-load reducing the blood pressure even further. Pre-hospital administration of CPAP to a suspected PE
patient may buy the patient time for the administration of "clot-busting" drugs called, thrombolytics, at the hospital.

6.
CPAP and Do Not Resuscitate, (DNR), Order:

In most states, a DNR is an Advanced Directive that covers some very specific procedures having to do with
cardiac arrest. Most DNR’s will not allow health care providers to administer chest compressions, insert an artificial
airway, administer resuscitative drugs, defibrillate or cardiovert, provide respiratory assistance, (other than suctioning
the airway and administering oxygen), initiate resuscitative IV or initiate cardiac monitoring. When a patient has a
valid DNR, and doctors and nurses stop focusing on treatment, and begin to focus on comfort measures only, this
is called Palliative Care. In some states, CPAP can be used as a form of Palliative Care, making the patient more
comfortable when struggling to breathe. Follow local protocol on the use of CPAP for patients with DNR’s.

CPAP and Children:

Many EMS systems place age limits on providing CPAP to children. It’s not uncommon to see protocols restricting
CPAP to patients over the age of 12. There are no medical contraindications to using CPAP on children of any
age. For example, CPAP is routinely used in Labor and Delivery, as well as the NICU. (An example only: EMS
should not be using CPAP on young infants and neonates due to the difficulty of application and the type of
equipment needed). However, applying CPAP to a child can be very effective therapy if the following two rules
apply. First, the patient has to be able to tolerate the treatment. If the child is fighting the treatment, it can actually
make the patient worse. Secondly, does the patient interface, (mask), get a good seal? Remember, one of the goals
for CPAP is to reduce work-of-breathing. If the patient is working hard-to-breathe, can tolerate the treatment and
has a good mask seal, what’s the downside to CPAP? There is none.

CPAP and Tracheostomy Patients:

Encountering patients with tracheostomy tubes is not uncommon in EMS. These same patients can obviously have
medical problems unrelated to the cause of the tracheostomy. Is it conceivable that these patients could benefit
from CPAP because of CHF or COPD? It’s not only conceivable, it’s likely. There are several ways to provide
CPAP to a tracheostomy patient; the key is, do they have a trach tube in place? Or just a stoma or hole? For
patients with a trach tube in place the first thing to determine is whether the patient is breathing through the tube
or is it capped? If the tube is capped that means they are breathing normally and CPAP can be administered with
a mask. The cuff on the trach tube may have to be inflated to get a good seal. A capped tube indicates that the
tube has a hole at the curve of the tube for the patient to breathe through. An uncapped tube may indicate that the
patient does not have an intact airway to the nose and mouth, so a mask may not be an option. Many trach tubes
have an inner cannula that can be removed and will allow the patient to talk if their airway is intact. When the
cannula is in place, it blocks the hole in the curve so no air passes the vocal cords. To tell the difference when the
cannula is in, it resembles the connector on an endotracheal tube, (ETT), allowing a Bag-Valve-Mask, (BVM), or
ventilator to be attached. If the cannula is out, the end is more flat and there is no connection for the BVM or
ventilator. To apply CPAP to a patient with a trach tube, the cannula has to be in place. In most cases, the patient
or a family member can assist placing the tube. If not, and protocols allow it, the cannula can be easily inserted
and once in place can be locked by turning the connector to the right. With the cannula in place, some CPAP
devices can be attached directly to the trach tube, once the mask is removed. By removing the mask and attaching
the device directly to the trach tube, the patient’s interface with the CPAP device was the only change; the device
will still function as before. There are people walking around with stomas with no tube in place. The only way to
place them on CPAP is to insert a trach tube, (not the standard of care for many systems), or insert an endotracheal
tube into the hole and attach the CPAP device to the ETT. Caution: The tube should only be inserted to the
point that the cuff disappears. Once the cuff disappears, the cuff should be inflated.

7.
When Should CPAP be Discontinued and Manual Ventilation Started?

CPAP should be discontinued when a patient goes from respiratory distress to respiratory failure. It is
recommended that all CPAP patients be continuously monitored using capnography/capnometry and pulse
oximetry. Oxygenation is obviously very important, but the true measure of a patient’s ability to move air is carbon
dioxide, (CO2). Patients in respiratory distress can have a relatively normal CO2 because they are compensating,
exhibited by the effort they are putting in to breathe. As the patient tires or their condition gets worse their ability
to compensate may no longer be effective. Once the patient starts to decompensate, their CO2 levels will start to
climb. As the CO2 climbs and converts to an acid, the pH will fall causing the patient to become acidotic and end
up in respiratory failure. The patient will exhibit a reduction in their work-of-breathing or effort-to-breathe,
(running out of gas), and will show signs of a decrease in their level of consciousness, (Narcosis from high levels
of CO2). These patients need to be ventilated manually or on a ventilator and are no longer candidates for CPAP.

Conclusion:

With the changes in medicine, both clinically and financially, EMS can no longer concern themselves with just the
time from dispatch to the arrival at the hospital. Not only will EMS be involved with patients before they call 911,
(Advance Practice Paramedics), they will also have to possess a greater understanding of how their actions, before
arriving at the hospital, effect care in the hospital. Research has shown that CPAP reduces the need for intubation
and that an intubated patient’s stay in the hospital is twice as long as non-intubated patients. It’s been reported that
one day in the ICU can cost as much as $8,000 with reimbursement being based on outcomes and not treatments.
Expanded use of CPAP can be a “win,” for not only the patient but the hospital as well as EMS. Some medical
directors have asserted, that due to short transport times, there was no need for an aggressive CPAP protocol. In
response, consider the following scenario where EMS does not carry CPAP.

EMS responds to a patient who is complaining of difficulty breathing. After assessing the patient they determine
that the patient is in CHF. The crew provides general supportive care, (O2, IV, and monitor), and administers
Nitroglycerin. The patient is placed on a stretcher and taken to the ambulance. Once the patient is settled in the
ambulance, the patient is transported to the hospital, about 10 minutes away. During transport, the crew called the
hospital and gave a report. Upon arrival at the hospital, the patient was unloaded and taken inside where the triage
nurse directed the crew to a cardiac bed. The patient was transferred to the bed and a report was given to the nurse.
The ER doctor arrived at the bedside and quickly ordered the patient to be placed on CPAP. At this point, the unit
secretary pages Respiratory Therapy to place the patient on CPAP. Respiratory Therapy arrives a few minutes later
and starts the patient on CPAP.

This is a pretty typical call for EMS just about anywhere. EMS clinicians learn early on that patients don’t call at
the first sign of trouble. In this scenario, how much time would have passed from first contact with the patient to
the start of CPAP by Respiratory, (assuming Respiratory and a CPAP machine are available). If the patient is on
CPAP within an hour of first contact, the system does pretty well. Why should a patient continue to suffer and
potentially deteriorate for another hour? (Answer: They shouldn’t.) Especially when we consider the patient may
have been spiraling down several hours before calling 911.

Other factors to consider:

- What if Respiratory Therapy is not available?
- What if the closest hospital is on divert?
- What if the hospital is extremely busy and does not have a CPAP machine available?
- What if you are on an ALS engine waiting for a transport unit?
8.
CPAP is a cost-effective, life saving device . . .

. . . that should be a standard of care in every EMS system.

“Education is learning what you didn't even know you didn't know.”

Daniel J. Boorstin

9.
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Aguilar, S, J Lee, and E Castillo. "Assessment of the addition of prehospital continuous positive airway pressure
(CPAP) to an urban emergency medical services (EMS) system in persons with severe respiratory distress." Journal
Emergency Medicine. (2013)

Chekhov, A. (n.d.). Brainy quotes. Retrieved from

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Chronic Obstructive Pulmonary Disease." JOURNAL OF PHYSIOLOGY AND PHARMACOLOGY. 58.5

(2007): 539-549. Print.

Confalonieri, M, A Potenaonieri, and G Carbone. "Acute respiratory failure in patients with severe community
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Covelli, Henry, Barry Weled, and Jerome Beektnan. "Efficacy of Continuous Positive Airway." Chest. 81.2 (1982): n.
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Goldberg, P, H Reissmann, and F Maltais. “Efficacy of noninvasive CPAP in COPD with acute.". European
Respiratory Journal. 8. (1995): 1894–1900. Print.

Glasser, K, J Civetta, and R Flor . "The use of spontaneous ventilation with constant-positive airway pressure in
the treatment of salt water near drowning." Chest. 67.3 (1975): 355-57. Print.

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11.
Continuous Positive Airway Pressure

(CPAP)

Steven LeCroy, MA, CRTT, NREMTP

[email protected]

11300 - 49th Street North

Clearwater, Florida 33762-4807
727-573-0088 / 800-237-6418

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