2004 OPEN FORUM Abstracts
NONINVASIVE CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) AND NONINVASIVE POSITIVE PRESSURE VENTILATION (NPPV): SIMPLIFYING CPAP DELIVERY FOR QUICK APPLICATION AND ITS IMPACT OF REDUCING ENDOTRACHEAL INTUBATION AND ICU ADMISSIONS
David
Smith RCP, RRT-NPS, Hal Herlong, RCP, BS, RRT-NPS, Rommel
Silverio RCP, RRT-NPS, Kiumars Saketkhoo MD. Presbyterian
Intercommunity Hospital, Whittier, California
#
OF PATIENTS 2002 = 48 2003
= 195 2004 (2Q)= 145
Background: In 1984 a policy was created
to utilize non-invasive CPAP and in 1994 one for noninvasive positive
pressure ventilation (NPPV). These modalities were implemented for
patients that would benefit from an increase in FRC eg. Cases where
severe hypoxemia (PaO2 < 50 or SpO2 < 90% with FIO2 > 0.50)
caused by intrapulmonary shunt. In the use of CPAP systems utilizing
oxygen blenders and Rudolph valves were built to meet this need but
required excessive time to reassemble. The availability of
non-invasive ventilators able to provide high FIO2 was effective but
costly. To meet the needs of managing a higher volume of patients
with scarcer resources to meet this demand, efforts were made to
simplify the application of CPAP. Data was collected to measure the
number of ICU versus non-ICU admissions resulting from the quick
application of noninvasive therapies.
Method: In 1999
discussions were held and the following design changes were
implemented and continue to be used today: A Hudson wye connector is
used for inspiratory and expiratory flow and patient connection. A
cuffed facemask with hook ring is used as the patient interface. A
rubber strap behind the head is adjusted for proper fit to the four
points on the hook ring. The inspiratory side consists of a one-way
antisuffocation valve adapted to a T piece with 1-liter reservoir bag
then attached to the wye connector. This provides adequate
inspiratory volume and protection against loss of source gas in a
closed system. The expiratory side consists of an adjustable PEEP
valve adapted to the wye to provide CPAP. Oxygen is supplied via the
pressure sensing port on the wye connector from a flowmeter capable
of delivering enough gas to maintain reservoir bag inflation
throughout the respiratory cycle. CPAP is titrated from 5 to 10 cm
H2O. FIO2 is delivered as 100% oxygen source via flowmeter from
hospital supply or tanks if transporting. Oximetry is maintained >
92%. Oxygen is weaned upon signs of improvement by placing a nasal
cannula under the mask at 6 lpm and changing the CPAP mask’s
gas supply to air. CPAP is titrated to 5 cm H2O and the mask is
discontinued when SpO2 is maintained on nasal cannula alone and
dyspnea and accessory muscle use is relieved.
Results: Over
two years (2002-2004) data was collected on patients who received
CPAP or NPPV in the Emergency department. 388 patients avoided
endotracheal intubation. 191 (49%) of these patients avoided ICU
admission.
Conclusion: Simplification of a system to supply
CPAP via mask quickly in the treatment of severe hypoxemia with loss
of FRC resulted in patient improvement, avoided intubation and
avoided transfer to higher level of care with resultant cost savings.