Written by Jim Augustine, MD
Attack One responds to a call for a person who can’t breathe. A concerned husband meets the crew at his house’s front door. His wife sits in the back bedroom in severe distress — they can hear her breathing from the porch.
The crew quickly moves to the patient, the lead paramedic carrying the airway bag and taking the position closest to her. The woman is sitting upright in a chair, eyes closed, and at first seems unable to speak. In that position, the paramedic notes, the patient is diaphoretic, breathing rapidly and noisily, and has distended neck veins and edema in her feet. They ask her if she’s having pain, but she doesn’t respond.
The paramedic touches the woman to begin assessment, and her eyes open briefly. The crew places a pulse oximeter on her finger and checks a quick blood pressure. Her oxygen saturation is in the high 60% range, pulse rate regular and rapid. An oxygen mask is applied at high flow. The paramedic opens the airway kit, preparing for endotracheal intubation, while her partner applies the cardiac monitor. “You going through the nose or the mouth?” he asks.
The patient opens her eyes and mouths a few syllables they can’t hear. They ask her to repeat what she said; again the response is inaudible.
Her husband speaks up: “She’s saying ‘No tube’!”
The crew looks up at him. “Don’t put the tube in,” he reiterates. “She’s been on the machine before, and she doesn’t want that ever again. The tube means the machine, and neither of us will agree to that. Don’t put the tube in.”
That makes it fairly clear.
The oxygen has improved the patient’s saturation to the low 70s, but her distress hasn’t changed. She’s on Coumadin, so the crew places an intravenous port carefully, to avoid excessive bleeding. Her elevated blood pressure gives them an opportunity to use nitroglycerin to assist in offloading some of the heart workload, and they ask the husband to check her usual daily dose of diuretic medication. But these medications are going to take some time to provide relief, so the medics consider their options.
Enter the CPAP
The crew had recently trained on a new assist device that provides continuous positive airway pressure, or CPAP. The equipment had been added to their vehicle, and their protocols adapted to add its use for patients with this presentation. They retrieve the equipment, explain the procedure to the patient and her husband, and apply the tight-fitting mask to the patient’s head.
“We’re using this to assist your breathing without having to put a tube into your airway or assist you with a ventilator,” the lead medic tells her. “It’s a little noisy and will be tight on your face, but it’ll make it easier for you to breathe and relieve the stress on your heart and lungs.”
This case demonstrates use of CPAP in a patient with congestive heart failure. In these patients, CPAP ventilation increases intrathoracic pressure and decreases venous return. Although it’s an easy explanation for patients, it does not, in fact, “push fluid out of the lungs.” Reducing venous return decreases the work of breathing, assists the patient with inspiration and reduces bronchospasm. Together, these physiologic effects result in better oxygenation of the heart, better heart function and improved perfusion to other organ systems. Research has verified better outcomes for CHF patients managed with CPAP.
Has your department considered purchasing a CPAP for emergencies? Or are you already trained on CPAPs? CPAPs are often used as noninvasive treatments to sleep apnea, or instances when a person, in his or her sleep, is not breathing for extended periods of time.
Image copyright The Mayo Foundation for Medical Education and Research.