The Science Journal of the American Association for Respiratory Care

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.

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