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.

 The Advanced Life Support Patient Care Standards Continuous Positive Airway Pressure (CPAP) Medical Directive actually does direct paramedics to increase/titrate the pressure and the FIO2.

The Medical Directive calls for paramedics to consider increasing the FIO2 if the patient SAO2 is < 92% despite treatment and/or 10cmH2O pressure or equivalent flow rate of device as per BH direction.

The directive also lists the titration interval of 2.5cm H2O every 5min to a maximum setting of 15cm H2O and a maximum FIO2 of 100%.

Therefore to answer your specific question, as long as your patient is in respiratory distress (as evidenced by a paramedic clinical judgment and a significantly elevated respiratory rate, accessory muscle use etc..) and the oxygen saturation is < 92%, paramedics should titrate the CPAP pressure and FIO2 as per the Medical Directive.

Airway/Breathing,Continuous Positive Airway Pressure (CPAP)

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