Noninvasive Ventilation in Acute Cardiogenic Pulmonary Edema ED Patients
By Keith Wesley
Collins S, Mielniczuk L, Whittingham H, et al: “The use of noninvasive ventilation in emergency department patients with acute cardiogenic pulmonary edema: A systematic review.†Annals of Emergency Medicine. 48(3):260-269, 2006
The Science
The authors of this study conducted a Medline search of all studies evaluating the use of CPAP in the ED for the treatment of acute cardiogenic pulmonary edema (CHF). The authors compared the effect of standard therapy to CPAP and standard therapy on primary outcomes of mortality and intubation rates.
A pooled patient base from all studies examined showed a significant reduction in both mortality and intubation rates. The authors concluded that adding CPAP to standard therapy was advantageous.
continue through the link…
http://www.jems.com/columnists/Wesley/articles/242…
I agree - I’ve seen it work. In fact, it works great, if the patient can tolerate it. The only problem I’ve seen involves ill-fitting masks. Because the masks have to be tight in order for the noninvasive ventilation to work correctly, patients suffer from skin breakdown. We use Tegasorb (or Duoderm) around the areas where that breakdown is most likely to occur.
I have to also say there may be a turf war brewing (again). I know there has been some consternation between the respiratory care folks and the EMS folks when it comes to prehospital ventilation, but the introduction of CPAP/BiPAP in the field only adds to it. We (the RCPs) usually wonder if they really know what they’re doing with those little vents they use… Just my opinion…
- lpressley130 Said:
My impression is that you are justified in your concern. We were introduced to two CPAP systems during our "Advanced Airways" EMS class [before I put my Paramedic certification on the back burner in lieu of my post-bacc]. We were taught the (very basic) principles behind the use of the equipment (control settings & peep valves, etc.), but there wasn't very much time given to things like potential for parenchymal injury, for instance. The prevailing attitude of our instructors frequently seemed to be that, with the short transport times usually involved, many of the more subtle details involved with ventilation weren't as important simply maintaining a patent airway. The goal was certainly to familiarize us with the equipment with the understanding that individual transport services & medical directors would likely have differing protocols for the use of the equipment.
In large part, this is one of the reasons I'd like to receive advanced medical training. I'm that guy who is inclined to be saying, "...but, ... but what if... ... but why do...?" to constantly be told my questions or comments are beyond the scope of an EMT's practice. Eventually, it was gently pointed out to me that if I was really so concerned about technical fine-points, I should get my "ass into a damned medical school."
It seemed like advice worth taking since it's really what I've wanted to do all along, but I thought I was too stoopid...
During one of my clinical days in the local ED, a guy was brought in suffering from pretty bad CHF. A nice RT showed me how to set up the BIPAP, and fit the mask on the patient. She taught me everything I had ever wanted to know about PAP devices plus a couple things that went a little over my head. The patient went from looking almost dead (kind of ashen) to pink & talkative in about 15 minutes. I was really impressed, and that has been one of my medical 'inspiration'
moments ever since.Tim
Hmmmm…not had time to read the referenced article but this is a rich ground for debate. Gim’me time to come up for air, read the article & make a response - should be fun!
Tim:
I find your comments interesting. As you found out, ventilation is a topic which is near and dear to respiratory therapists. I agree with your desire to have more advanced training. I used to take the EMS students around during their rotation in our department and they were to just see what we did clinically. They were also allowed to help with bagging a patient during a code, etc. because they were BLS certified. But, the rotation only lasted about a day-if I wasn’t assigned to the unit that day, it was a real boring rotation. They didn’t cover too much more than that in the classroom. I just found out the paramedic program at our CC no longer offers OR rotations for intubation! They now just intubate the dummies (i.e., SIM Man. Now, don’t get me wrong, SIM Man is cool and everything, but he doesn’t vomit on you like a real patient would…).
Have you ever had the opportunity to set up a BiPap or CPAP machine and place it on yourself (or set up a vent with PSV and CPAP)?
LM
- lpressley130 Said:
Same here. Our instructors talked about all the cool things they were allowed to see and do when they did their clinical stints, but we were only, grudgingly, allowed to start IVs, draw & push any medications that we had studied (we were quizzed thoroughly by the nurses), draw blood by venipuncture (or via a fresh IV stick), and yes, bag patients until someone from Anesthesia showed up to do an intubation. If we were lucky, we'd be allowed to stay and observe.
I think I got to do a little bit more, perhaps, because my clinical supervisor seemed to trust me (and another classmate) a bit more than our HS-aged counterparts. She showed me how to insert a NG tube, and how to irrigate a foley catheter. I also got the privelege of changing a few bed pans too, but everything we were allowed to do was exciting due to the novelty of helping people rather than practicing on mannequins.- Quote:
We each got to try the CPAP devices. One of the devices was pretty bare-bones (and cheap), and the other had a few more bells and whistles (the more expensive one). I think we emptied 3 or 4 cylinders of oxygen just trying things out. Those things went through a prodigious volume of gas on their highest settings.
I understand what Pressure Support Ventilation is, but only because I bugged the nice RT lady about it until she explained it to me to my satisfaction (and then I did some reading on my own). It sounds like something that won't find a it's way into the [EMS] field until it is dumbed down, erm... I meant "optimized" for implementation by EMS personnel. As of my last sememster at the CC EMS Program, PSV wasn't even mentioned in the "Advanced Airway" syllabus or in any of my Paramedic textbooks. That may have changed recently, but I wouldn't know about it. I imagine that I will learn all about it in agonizing detail if I can get myself into medical school, however. Suppose I better get back to work on the O-Chem homework...
- T_Forsythe Said:
OK - I'll get back to work my Chem!
Hi Tim:
In my quest to make sure I have all of my CEUs for my license, I signed up for online credits on Respironic’s website. Respironics is the company that coined the acronym ‘BiPAP’. There is a presentation on NPPV and it’s pretty good. I use their product (the BiPAP Vision) at a facility where I work. The site is - http://elearning.respironics.com/index_f.asp.
Sign up is required and free.
Thanks for the link! I’ll be sure to check it out.
This brings to mind an interesting dilemma, though. I ask myself if I should spend time maintaining certifications that will likely be superceded by training I will receive if I am accepted into medical school. If, however, I don’t get accepted somewhere, I’m pretty sure I’ll be wanting to keep the certifications I already have until I can get in. It seems wise, perhaps, to maintain my certifications, but I keep wondering if my “hedging” is a subconscious ‘hint-to-self’ that I don’t feel confident enough about my abilities.
Does anyone else do this, or is it just me?
Thanks again,
Tim
Hey Tim,
I continued to renew my RN’s license until the renewal fee went way up, sometime during med school. At that point, I knew I wasn’t going to need the license and I definitely needed the money.
Mary
Tim:
It might sound stupid, but I worked hard for the little RRT degree and plan to maintain the license - right now it’s only $25 a year to renew. I’ve transitioned to another career (in IT), but have kept the RRT license anyway. It’s come in handy…
Good to know! It seems like I have to put in a pretty substantial amount of training time to stay current (compared to RNs, anyhow). Still, skills are skills & I’m inclined to hold on to 'em until I have better ones to replace them.
Tim
- lpressley130 Said:
Yeah, that's actually closer to my line of thinking. Not surprisingly, I'm a huge packrat when it comes to stuff... especially books. I've never sold a college textbook unless I absolutely deplored the text. My wife begs me to get rid of the things I'll likely never use again, but it is really hard for me to let go of them. I know I may regret my massive collection one day (especially when it comes time to move again). In the mean time, I find comfort in holding on to anything with potential utility (fuel for the days following the apocalypse, if nothing else).
Tim
T:
Funny you should mention the packrat issue - my sister was at my place a couple of days ago and she informed me I didn’t need all of those college textbooks anymore. Of course, I beg to differ!!! I might need them someday. Besides, I have a few away to the local library…
I continue to re-new my RRT credentialing annually - matter of fact, I just got the bill a couple of days ago. Now, since I am not technically employed in the field of resp any longer, I am not considered an active practitioner, but I still desire to honor my roots.