Does cpap have to be used with nitro

Hi Doc(s), Two unrelated questions I’ve been pondering over the last couple of days: 1. In the field I’ve noticed some paramedics withhold dimenhydrinate administration if the patient has already taken any Gravol in the last 4-6 hours. However, the medical directive does not specify a time and simply states overdose on antihistamines or anticholinergics or tricyclic antidepressants. My understanding of their logic is that additional Gravol may cause an overdose in the patient however Gravol brand themselves recommend a dose of 1-2 50mg capsules every 4hrs PRN… Could you please provide some further clarification on this practice, and if we should still be administering it if we do not suspect an overdose but that the medication has been taken appropriately. (and similar practice for if the patient is taking tricyclics or anticholinergics as prescribed to them) 2. I recently had a COPD exacerbation patient who I believe would have benefitted greatly from CPAP. He had equal lung sounds through all fields with no paroxysmal chest movement, however there was a recent history of a collapsed lung approx. 6 weeks prior. (Unknown cause, from his history I suspect possibly a bleb/bullae) The current extenuating circumstance of COVID-19 aside, should CPAP be considered in this patient? Although I am not suspecting a current pneumothorax, due to the recent history I would think that weakening of the lung tissues could put the patient at greater risk for a recurrent event if subjected to significant positive pressures. Thank you and stay safe!

When we have a patient who is sob and we have decided to put CPAP on, what code and ctas is mandatory even though they are stabilized because of cpap? Is it code 4 ctas 1 always? And are we suppose to pre alert for an RT?

Are we entitled to the scientific reasoning why we are no longer providing CPAP to patients? What is the expectation when I am unable to confirm COVID-19 and my immediate presentation would improve with CPAP administration?

Question: In the event we have a patient who is STEMI positive, with symptoms of CHF (crackles/pitting edema) who is hypertensive >140 systolic BP are we to treat with 0.8mg of nitro for the CHF or 0.4 mg under the ischemic chest pain protocol? Also with the new STEMI standard dropping down to 3 – 0.4mg SL doses of nitro maximum, will that change out CHF protocol for nitro administration if both problems present together?

Question: Is PEEP being considered for inclusion into the paramedic scope of practice? I recently had a patient who was in CHF to the point of unconsciousness whom we would have absolutely given CPAP had he been conscious. Although PEEP isn’t exactly the same as CPAP, would it not have potentially provided some benefit?

Question: Some years ago during a recert in the fall a question was posed regarding administering a nebulized treatment of ventolin to a patient who otherwise would not tolerate an MDI but also had a fever above 38C (all other conditions met). The question was answered by stating if all attempts fail for use of the MDI, a nebulized treatment could be administered if all droplet precautions were taken (N95 worn, gown worn closed window to cab area, goes without saying truck disinfected). Is this in fact the case? (Updated)

Question: In a patient presenting with respiratory distress, crackles and a relevant cardiac history, I would assume that left ventricular failure/infarct would be a fair working assessment. If 12-lead indicated LV involvement occurring with hypotension that would place the Cardiogenic Shock and CPAP Directives out of parameters.

Crackles = no bolus, hypotension = no CPAP. Other than vitals/cardiac monitoring, oxygenation/ventilatory support as needed, it seems like a situation such as this one may limit pre-hospital management, as far as a PCP scope goes. Any comments or suggestions?

Question: If a person have a near fresh water (lake water) drowning and Spo2 <90 % severe SOB, and by auscultating lungs I hear Crackles all over the places mainly on lower lobes tachypnea and normotensive. As per CPAP protocol: indication severe respiratory distress and signs and/ or symptoms of Acute pulmonary edema or COPD is the indication, and patient is above 18years and no contraindication met, can I apply CPAP on this patient ? If not please tell me why and I know Nitro is not applicable in this case because this is not a cariogenic pulmonary edema.

Question: In regards to the CPAP medical directive, it states in the ALS PCS Companion document that CPAP is the treatment for Acute Pulmonary Edema (REGARDLESS of origin). Does this mean that the cause does not need to be cardiogenic in nature? Could you please elaborate on this?

Question: I was going over the CPAP standing order today and would like clarification on whether the contraindication “Major trauma or burns to the head or torso” only means for a new occurrence or does it also include persons with prior existing major trauma or burns to head and torso?

Question: A patient is presenting with pulmonary edema. Patient became more symptomatic before calling and dyspnea worsened. Upon gathering history and taking vitals, they meet the criteria for Nitro and CPAP. The patient is currently prescribed Lasix for fluid in the lungs from doctor visit one week ago.

With the history of pulmonary edema and being prescribed Lasix for fluid in the lungs, would this now be considered Non-Acute Pulmonary Edema?

I need a better understanding of Acute Pulmonary Edema vs. Non-Acute Pulmonary Edema. The CPAP protocol indication lists: Suspected Acute Pulmonary Edema.

Since the pulmonary edema is non-acute would CPAP and Nitro be withheld? Or, since the symptoms have worsened, provided I can recognize a patient that is truly in need of CPAP and Nitro, would I administer them? I want to clarify – thanks.

Question: I have been talking with my paramedic colleagues and I am wondering about the role of CPAP and aspiration. My understanding of the Medical Directive is that CPAP is not indicated for pneumonia or aspiration but rather severe SOB from either COPD or pulmonary edema. Can you please clarify the role of CPAP for respiratory distress patients with either pneumonia or aspiration as the underlying precipitating factor for their SOB?

Question: My question is in regards to pneumonia and continuous positive airway pressure (CPAP). Bacterial infections are a common trigger for chronic obstructive pulmonary disease (COPD) exacerbations.

If we have a patient who has possibly developed a pneumonia (isolated crackles mid lobe in one lung, low grade fever, purulent sputum) but is in respiratory distress with a history of COPD and is showing signs of a COPD exacerbation (decreased breath sounds in bases, showing signs of hypoxia, accessory muscle use, tachypnea, mild diffuse exp wheezes), are we not to treat with CPAP and just use bronchodilators and high flow O2? Thank you!

Question: Last night I had a 75 year old patient calling because he was SOB x 2 days with it worsening this evening. Patient could not sleep (could not breathe very well laying down) and was more SOB on exertion. I could hear fine crackles in the bases of his lungs.

There was no ischemic chest pain or NTG history. His vitals on contact were HR 90, BP 188/70 (ish), SPO2 95% on Room air, 100% on NRB, RR 24 verified with an with ETCO2 of 40mmHg, No ST changes in 12 lead.

He had some slight increased work of breathing on scene with mild increased diaphragmatic use but was speaking full sentences and in good spirits with us. Patient had a history of COPD and CHF. He also stated he had taken some of his Ventolin puffers prior to our arrival with no relief (probably made things worse). I wanted to treat him with NTG but he did not seem to be in enough distress initially, so I kept him on the NRB which he stated help initially. We got to the truck and started an IV enroute, then administered 0.8mg NTG. Literally… within about 2 minutes of the NTG admin, while I was patching, the patient had a sudden onset of severe SOB. We were right outside the hospital, so I grabbed my BVM, assisted his respirations distress until my partner could get us out of the truck and help me put CPAP on. CPAP helped and he was back to normal shortly after our transfer of care.

My question is, should I have used the CPAP right away with the NTG, even though the patient was not showing signs of severe respiratory distress at the time, and on numerous auscultations of the lung, did not have any increase in crackles… until of course, he developed that sudden severe respiratory distress? My gut was to CPAP him early, but I felt he did not fit the protocol yet given his level of dyspnea, SPO2 sats, RR and minimal accessory muscle use.

Question: I was taught that if there is some clinical improvement, when using CPAP, we are not to titrate the pressure any higher. I understand the rationale for this, however my question is, are there clinical guidelines that quantify a patient having sufficient “clinical improvement”?

Example being a patient breathing at a rate of 34 bpm with accessory muscle use, sp02 of 85%, audible crackles through all 4 lobes. With CPAP applied at 5 cmH20 vitals improve to RR of 28 bpm, sp02 of 91% and crackles remain. This patient has had a degree of improvement but would it not be advisable to titrate the pressure 2.5 cmH20 higher (after 5 mins) to attempt to further normalize the patient’s VS and clinical condition? Or is the goal to increase the sp02 above 90 % with no accessory muscle use and decrease RR below 28 bpm as the directive lists these as conditions needed for application.

Question: We are instructed to get the nitro in, if applicable, apply the CPAP and if there is improvement, do not remove the mask for additional nitro sprays. Is the improvement slight or significant? If slight improvement, do we leave the pressure at the slight improvement pressure or titrate 2.5cmH2O?

Question: If respirations are at or above 28, historically paramedics are taught to assist via BVM. What is the rationale with pulmonary edema to apply NRB with tachypnea instead of assisting with a BVM until CPAP and or nitro is prepared?

Question: VSA trauma patients – chest compressions and defib is the priority for this patient. C-spine maintained manually. In this scenario, is it mandatory to apply a collar prior to a shock being delivered as the manual c-spine must be removed to deliver the shock?

CPAP- indication b/p 100 or above systolic. Contraindication is hypotension. If CPAP is applied while normotensive, can we leave the device on until they become hypotensive or we must remove when b/p drops below 100? Thanks.

Question: CPAP for CHF and COPD is to maintain a constant pressure in the airways (splinting with COPD) and to help push the fluid out of the alveoli and into the circulation with CHF. Would paramedics who do not have CPAP available be wrong, if the patient is conscious and tolerates, assist each inhalation with a BVM to increase tidal volume and create more positive pressure during inhalation, although not maintained with exhalation, in an attempt to force the fluid out with CHF. Debate is that we assist the ventilation at one breath every 5 seconds or 12/minute unless hyperventilating due to head trauma and respiratory problems with coning of the pupil(s). Thanks for the assistance.

Question: I have heard from our base hospital that MAC is considering removing KING-LT airways from the directives? Is this true, and if so, what supraglottic rescue airway option are they looking at going to, both for ACP’s and PCP’s. Not every patient can be ventilated using BVM alone.

I’ve also heard that they are looking at removing needle cric and intubation from ACP scope? If this is true, then why? Intubation does have major problems in the pre-hospital setting, but outside of cardiac arrest it is a very valuable method of controlling the airway (the gold standard) especially for long transport times or complex patient presentations.

Finally, I understand the theoretical rational behind not using CPAP in asthma PTS, but there are services in North America using it for end-stage asthma exacerbation as a option before intubating the patient. They combine low levels of CPAP (3-5 cmH2O) with a salbutamol nebulizer tied in line to the CPAP mask and are getting good results.

Is there any possibility of a clinical trial of CPAP in asthma exacerbation refractory to salbutamol/epi alone? Is there evidence against using it in asthma (besides theoretical problems).

Question: If a patient meets the protocol for having CPAP treatment but they have a valid DNR Confirmation Form can a PCP still administer CPAP?

Question: We had a patient who presented with bi lateral crackles and patient was in obvious distress and fit all of CPAP criteria, however the patient had a temp of 38.5. I remember that during our training it was clearly demonstrated that a patient with pneumonia is contraindicated for use of CPAP. Upon looking over the protocols it is not mentioned as a contra indication. Would CPAP be an appropriate treatment? If so would it still be appropriate if this patient was suspected of having pneumonia a few days prior by nursing staff. Thank you.

Question: A couple of questions in regards to CPAP use for acute pulmonary edema. I wondered if the medical directive intended for CPAP use in other cases of acute pulmonary edema other than the situation arising from heart failure. For example secondary drowning several hours after initial insult or inhalation injuries in the absence of facial or thorax burns that could be seen with chemicals or fire? It would be reasonable to assume that these insults would cause trauma to the lung tissue and increase the risks for developing pneumothorax as a complication, however in instances like this would CPAP be recommended, beneficial or allowed.

Second part would be the use of CPAP for those with complex medical issues such as those patients with Hx of asthma, COPD and CHF. If you where to treat with CPAP for say evidence of acute pulmonary edema and crackles resolved, but wheezes remained would there be benefit to consider ventolin for bronchoconstriction via MDI or neb through the CPAP device? Typically ventolin is not considered in these instances but auscultation in the prehospital setting has limitations and with complex medical histories cardiac asthma and COPD exacerbation may also be part of the overall medical situation.

I thank you for your comments and insights.

Question: In the area in which I work, there exists a statistical cluster of clients with Myasthenia Gravis. One client that I have now transported at least three times has got the message to call at the first sign of increasing SOB. Most recently he woke up at about 0300 feeling a bit more SOB than normal and not quite right. When we arrived at his house at 0600 he met us outside ambulatory and he had a temp of 39.8C. He was tachypneic. He was in respiratory distress related (In my opinion) to both his MG as well as pneumonia. He adamantly refused the stretcher. He stated that as per his directions he had taken a dose Mestinon when he awoke and that it had not helped. He had a weak or pretty much absent cough. He was placed on placed on high flow O2 by ‘Flow Max’ and was given at least one Ventolin treatment again using the ‘Flow Max’. His condition improved slightly. He was transported with great haste. I have reviewed MG as well as the action of Mestinon. At this point in his disease process he is still requesting that all that can be done be done. Do you have any suggestions as to how we can better care for this client? Putting headers on the ambulance, installing ‘NOS’ or a spoiler is not an acceptable answer. Is CPAP a possibility? I am aware that pneumonia is a relative contraindication for CPAP use. The mechanism of the two disease is quite different but the inability to expand (active muscle use) the chest seems to make them similar. I have attempted to reseach an answer and the best I have gotten after talking with a couple of ED Docs is, ‘Good question. Might buy you some time. How fast can you drive?’ Thank you for your time in considering and answering this question

Question: I have a question about a call. Male patient severe SOB. Crackles throughout with a GCS of 4, suspected acute pulmonary edema. Obviously patient of out nitro protocol. Patient’s spo2 31 and 42% with mottling noted. Patient’s initial pulse 42 with a respiration rate of 33. CPAP is contraindicated at this time so ventilations assisted via BVM. Enroute patient’s GCS improves to 15 and spo2 increases to 99% with ventilation assist. At this point could CPAP be applied or is it like the nitro protocol, once your out your out?

Question: With regards to the CPAP protocol, one contraindication is a tracheostomy. If this was just temporary and the tube had recently been removed, would CPAP be able to be administered?

Question: On page 11 of the new Medical Directives it states that vital signs have been kept constant throughout the directives and that any exceptions are clearly noted in each directive. Tachypnea is defined as 28 or > however, I noticed confusion amongst peers stating condition for CPAP was still at 24b/m or >. New protocol simply states tachypnea as the condition. Please clarify