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The National Association of EMS Physicians recently released a position paper on the applicability of Noninvasive Positive Pressure Ventilation (NPPV) in prehospital care. What does this position paper mean and why is it important?
Listen now to this free webcast, sponsored by Airon Corporation and presented by Joseph Holley, MD, FACEP, who describes what NPPV is; reviews why it is used and for which patients/symptoms; discusses how it is provided (when to use mask CPAP and when to use mask ventilation); reviews training required for EMS providers; and discusses why NAEMSP put out this position paper and what it means for the future of prehospital respiratory care.
After viewing this webinar, you can visit Rapidce.com to take the accompanying test and earn 1 hour of continuing education credit approved by EMS World, an organization accredited by CECBEMS. It costs $6.95 to take the test.
The following questions were asked by attendees during the live presentation of the webcast and answered now by Dr. Holley.
1. What is your opinion of using a sedative like ativan or versed for these patients? Be careful, as there isn't much data. Sedation can counter the anxiety, but that’s often due to the respiratory distress, hypoxia, etc., so these drugs may lessen their ability to cooperate.
2. Are there any known brands of CPAP masks that can be sufficiently sterilized thus allowing reuse of the mask and reducing cost? Not to my knowledge. You would need to check with the manufacturers.
4. In regard to your statement about CMS reimbursement, is anybody lobbying them about paying for it when it is not used in conjunction with intubation? Yes, but CMS is slow to move on such issues.
5. Our CPAP can set the tidal volume. What would you suggest as a starting block? My system recommends 1000ml. Does that not seem high? Yes, it does. Usually 750 is okay. Bad COPD patients or bariatric patients may need higher volumes.
6. Is there a maximum dose for nitrates in CHF, or should it be as much as necessary? As long as the patient's hemodynamics can tolerate it, give nitrates.
7. When I think of the lower respiratory system maintaining a normal internal pressure to remain inflated, I think of atmospheric pressure. Are 5-10cm/H20 higher than normal atmospheric level (14.7 lb)? CPAP is in addition to normal atmospheric pressure.
8. Once the device is applied, does it stay on and how do they come off? Some services hesitate to take it into the ED due to cost and possible loss of equipment. Patients can be weaned as their symptoms improve. Usually the only thing you would leave in the ED is the disposable component anyway.
9. Does the use of NPPV affect capnography readings? No.
10. My experience with oxygen use has been that oxygen often isn't as much an issue as it is to open them up so they can breathe. Do you concur? Yes, usually a ventilator problem.
11. What is your opinion of pulse oximetry? Do you think it is reliable in field? It’s a great tool with some limitations.
12. This would also be indicated, I imagine, for HAPE (High Altitude Pulmonary Edema), up to the point of their respiratory compromise from work of breathing. Do you agree? I do agree, although data is sparse.
13. Are there any indications that CPAP would be useful for HAPE or HACE? Which would be more beneficial for these types of patients—CPAP or the Gamow Bag? See above.
14. Would it be beneficial in carbon monoxide inhalation? Yes, with maximum oxygen.
15. Can you use a in-line nebulizer with the CPAP? Most systems, yes.
16. Can you attach an ETCO2 to a CPAP? Most systems, yes.
About the Presenter
Joseph Eugene Holley, Jr., MD, FACEP, has extensive experience in EMS, including specialty areas such as confined space, motorsports and event services. He currently serves multiple EMS systems in West Tennessee, including the Memphis Fire Department, making him the most active EMS medical director in Tennessee. In addition, he is a member of the Eagles Consortium, comprised of the EMS Medical Directors of the nation's largest municipalities. He is also the State EMS Medical Director for Tennessee. Dr. Holley is the director of the Emergency Department at Baptist Hospital Collierville and continues to work clinically on a regular basis. He provides medical direction for a large service paramedic education program. He is also medical director of Tennessee Task Force One FEMA USAR team. He has been deployed more than 20 times to such events as 9/11 at the Pentagon, Hurricanes Katrina, Gustav and Ike, among many others. Due to this extensive experience, he is now the medical unit leader for FEMA’s Incident Support Team.