Training Day: CPAP early, CPAP often

Tim Nowak // September 3, 2019

CPAP should be used as a noninvasive positive pressure ventilation tool early on in a treatment regimen for respiratory distress

Wheezing without a “shark fin” capnograph – CPAP!

Wheezing with a “shark fin” capnograph – CPAP!

Stubbed toe – CPAP! (OK, maybe not this one.)

Today’s CPAP devices are a fraction of the overall cost, simple in design and are entirely disposable, from the mask all the way to the oxygen connection. (image/Bound Tree Medical)

CPAP – continuous positive airway pressure – is an often underutilized treatment option in EMS, and its clinical acceptance and progressive consideration is different from region to region.

In some states, it’s reserved for paramedics, while in others, EMTs have had this valuable skill in their scope of practice and arsenal for a couple of decades.

Nevertheless, CPAP implementation comes down to training, criteria recognition and overcoming a reliance on (and belief in) nebulizer therapy only.

Physical signs of respiratory distress, pursed lips, abnormal lung sounds, decreased pulse oximetry levels and tachypnea are all classic clinical indicators for the use of CPAP.

As an educator, what should you instill into your providers’ minds? What cases can you present that will help to reinforce CPAP use early and often?

Asthma without relief

Teach providers that CPAP isn’t designed as a life-or-death treatment. It’s designed to prevent the patient from experiencing a life-or-death event. As such, it shouldn’t be reserved as a last-ditch effort. Rather, it should be used as a noninvasive positive pressure ventilation (NiPPV) tool early on in your treatment regimen, especially if Plan A isn’t getting the results that you need.

If your initial albuterol and ipratropium nebulizer treatment just doesn’t seem to be doing the trick, then your second one likely won’t change the result much, either. Instead of prolonging the inevitable (and continuing your patient’s exacerbation), transition to CPAP early.

While albuterol can bronchodilate chemically, CPAP can do it mechanically. Combine the two and you’ve developed a “super neb,” a mechano-chemical treatment option that tackles this illness process on both fronts and with force.

Crackles, rales and rhonchi

We place a lot of emphasis on lung sound recognition, at least in the didactive setting, throughout both EMT and paramedic curriculums. What we don’t emphasize enough, however, is how to treat these abnormal sounds. We seem to automatically correlate wheezing with asthma and then to a nebulizer. But what if the lung sound is not wheezing?

As an instructor, build your case studies to emphasize this. Include pneumonia with crackles (rales), emphysema with rhonchi and pulmonary edema with rales (crackles). Your nebulizer may help these patients a little bit or initially, but it’s not the most-indicated treatment option (sounds like a National Registry question, right?).

CPAP, however, is. “Splint” the airways open when they’re having difficulty doing it on their own and when they’re constricted, trapping air or have decreased surface area available for gas exchange. Build your case scenarios around this premise – around the need for splinting, not just smooth muscle relaxation.

Not all that wheezes is asthma

Yes, wheezing is likely associated with asthma. But, it’s important to remember that wheezing is an expiratory sound, while rhonchi is an inspiratory sound (classically, at least).

Emphysema – bronchial narrowing and air trapping – can present with wheezing sounds, too. Throw in a little excess mucus and now you can get all sorts of “rough” sounds within the lungs. Will bronchodilation with a nebulizer help? Sure ... probably ... maybe.

Is it the right, or best, fix? No. CPAP is.

When you’re training your next round of EMT or paramedic students or breaking in your next continued education lecture for the month, set your students (and their patients) up for success by introducing something with proven success and some positive reinforcement. Get them thinking about CPAP early and often.


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