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6 Major function of the Upper Respiratory tract is to warm, filter and humidify air. Discuss the consequences of intubation to the air passages and lungs e.g. dry O 2 delivered, mechanisms for moistening air, clearing particles (nares), etc. bypassed when an ETT is in place. Start building the platform to illustrate the benefits of CPAP for certain patients.

7 Gas exchange is the main activity in this area. describe the size of the surface area across which oxygen diffuses (70 square meter) and that we can provide interventions that help to reverse conditions that diminish the size of the area of diffusion - e.g. ventilation for patients with pulmonary edema, ventolin for bronchospasm, ventilation of respiratory depression in overdose, etc. Another gentle nudge early on to illustrate CPAP benefit without going into too much detail about it yet.

8 Oxygen availability for body tissues and diffusion of gases can be affected in few ways. 1) Diffusion gradient will determine how much gas diffuses. 2) Amount and functionality of alveoli will determine the amount of surface area is available to diffuse the gas and thereby affect the amount of gas that is diffused. 3) The amount of capillaries able to carry the gas to and from the lungs will affect the overall diffusion. 4) Amount of HGB / blood available for carrying the gases. 5) The ability for HGB to carry oxygen - poisoning ie CO or Cyanide some of these factors are part of the V/Q mismatch CO2 diffuses quicker than oxygen.

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10 Have participants offer actions of diaphragm and intercostal muscles. Answers will appear on a click. On Inspiration the diaphragm contracts (drops) and the intercostal muscles contract (ribs go up and out)

11 The diaphram is the most important muscle in the respiratory cycle. On inspiration, the diaphragm contracts and drops down causing a vacuum which makes the chest expand and causes air to rush in. In Expiration, the diaphragm relaxes again and moves back up therefore pushing air out of the lungs. In knowing this concept, we now have a better understanding of why people in respiratory distress must be assessed completely Look test included we can assess how hard they are working to breath, which should be a passive function, instead of a Working process! Note muscle use, position they are sitting in, ability to speak ( # of Words), anxiety level

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13 Physical assessment can be a poor estimate of hypoxemia, which may not be evident until the oxygen saturation levels are quite low. Hypoxemia is especially hard to detect in the dynamic environment that exists in the back of a moving ambulance.

14 This sensor strip may be placed and taped to a finger, toe, earlobe or any other area that crosses a capillary bed. Based on normal conditions the unit displays the percentage of Hb saturated with oxygen together with a calculated heart rate.

15 When can the SpO2 be 100% and the patient is in great need of O2?? CO poisoning, the hemoglobin is saturated but with CO instead of O2. Anemia, all the hemoglobin are 100% saturated, but there are not enough red blood cells to carry O2, remember that 2% of the O2 is carried by the plasma and it can get values up to 400 so it can perfuse tissues. and add to the amount of dissolved O2 in the blood plasma

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17 Discuss the danger of O2 delivery based on SPO2 alone as related to cardiac perfusion! Many medics will still deliver O2 via NC b/c SPO2 appears fine (and is c/o SOB and/cp)

18 Referred in mechanical ventilation to denote the amount of pressure above atmospheric pressure present in the airway at the end of the expiratory cycle. The equivalent in a spontaneously breathing patient is CPAP. PEEP is set on the ventilator.

19 CPAP: Continuous Positive Airway Pressure

20 CPAP Physiological Effects: History of CPAP. Effects on Lung Inflation (FRC) Ventilation and Perfusion Lung Compliance - Work of Breathing (WOB) CPAP Delivery Systems Flow Generator and CPAP Valve Low Flow Systems Isobaric Valves WhisperFlow Generator Competition Vital Signs VF100 and Drager CF800 Clinical Applications Emergency Room ICU General Ward

21 Contraindications to CPAP Medical Contraindications Complications arising from CPAP 20

22 CPAP is Continuous Positive Airway Pressure The earliest description of positive pressure airway support applied to a spontaneously breathing patient appeared in 1912, when Sterling Bunnell, an anesthesiologist, reported the use of a Teter mask to maintain lung expansion during thoracic surgery. He used a slider and spring mechanism to oppose exhalation. In 1936 Poulton and Oxon designed a pulmonary plus pressure machine to treat pulmonary edema. This was the combination of a vaccuum cleaner and an adjustable spring valve. The air was warmed by placing a hot water bottle in the dustbag compartment of the vaccuum cleaner and by sucking the air from in front of an electric fire! Barach in 1937 worked with aviation researchers and applied positive pressure by face mask to pilots flying at high altitudes to prevent hypoxemia. In 1956 Avery et al reported internal stabilization of flail chest utilizing intermittent positive-pressure ventilation. In 1967 Ashbaugh used term CPPB to describe positive end pressure used in conjunction with IPPV supplied by a ventilator. This led to confusion as CPPB had originally applied to spontaneously breathing patients. The term continuous positive airway pressure was coined in 1971 by Gregory et al to describe an elevated airway pressure therapy for spontaneously breathing, intubated neonates. In 1972 Civetta used CPAP to treat acute respiratory failure (ARF) and in 1973, Barach used CPAP for COPD patients. In 1981 JB Downs et al invented a new venturi device for administering CPAP. This was known as the Downs generator and was first marketed as the Vital Signs In 1982 Sarah Kielty expanded the definition of CPAP to include adults and more recently patients without an artificial airway. The successes during the 1970s led other investigators to treat a variety of diseases with mask CPAP. Current application has expanded to include adults and more recently patients without an artificial airway. The application of positive airway pressure throughout the whole respiratory cycle to spontaneously breathing patients (Keilty et al. 1992).

23 Heart failure is on the increase as a result of successes in treating heart attacks and other cardiac conditions. As people with damaged hearts are living longer, they become more susceptible to heart failure. The study, which examined hospital discharges for fiscal 2000, found that a total of 1.38 million hospital days were associated with congestive heart failure. 15.8% of patients died while in hospital, and the average hospital stay was slightly less than 13 days. Data for the study was obtained from the Canadian Institute of Health Information Discharge Abstract Database, which covers about 85% of Canadian hospitals. The researchers analyzed data on patients who had been hospitalized with congestive heart failure as a most responsible, primary or complicating diagnosis. Statistics.htm

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25 FRC = the air remaining in the airway after exhalation

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29 These are videos I have to get the links from Rick so they ll play.

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32 PATIENT AIRWAY PRESSURES This slide illustrates simulated breath traces at atmospheric pressure (0cm H 2 O), and at 5cm H 2 O CPAP. Note that for inhalation of air to occur when breathing without assistance (0cm H 2 O), the generation of a pressure gradient is required: the pressure within the lungs is negative compared to that in the atmosphere, and consequently air is drawn into the lungs. Conversely, during exhalation, the passive elastic recoil of the ribcage elevates the intrathoracic pressure to above the atmospheric level and is therefore positive, consequently forcing air out of the lungs. The larger the drop in pressure on inhalation (i.e. the more negative it gets) the greater the patient work of breathing. When breathing with the aid of CPAP, the pressure within the lungs always remains positive.

33 Stent device use to keep a passage open in this case air pressure being used to keep the air passage open FRC Functional Residual Capacity

34 We breathe in (inspire) in order to transfer oxygen into our bloodstream and we breathe out (expire) to carry away carbon dioxide. This process works because of Partial Pressure The pressure of a gas mixture is equal to the sum of the partial pressures of its constituents. Example : Air at sea level has a pressure of 760mm Hg. Air is 21% oxygen and 79% nitrogen. Therefore the partial pressure of oxygen is 760 X 21%= 159mm Hg. Question. What is the partial pressure of Nitrogen at sea level?

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36 The diagram on this slide will show air entering the alveoli, a click will change the graphic to one showing air movement from the alveoli to the RBC and back. The blood supply arriving at the alveoli carries deoxygenated blood. This means that the oxygen has been used as the blood has been circulated round the body. Oxygen passes from the alveolar air into the blood because the partial pressure of oxygen in the alveolar air is higher than that in the blood arriving at the lungs It also applies the other way too! Blood arriving at the lungs has a higher partial pressure of carbon dioxide than the alveolar air, hence CO 2 leaves the blood and is expired.

37 1 cm H 2 O is equal to mm Hg. A 7.5cm H 2 O C.P.A.P. valve increases atmospheric pressure at sea level by 5.51mm Hg, and this in turn increases the partial pressure of the alveolar air by approximately 1%. This increase in partial pressure forces more oxygen into the blood. Even this comparatively small change is enough to make a clinical difference.

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41 Pathophysiology: Summarized as an imbalance in Starling forces.

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43 Classification: CV system: Increase HR. APE Sympathomymetic Increase Cardiac Output which will exacerbate CHF and or NO It exacerbates the underlying cause, the wheezing is caused by the fluid in the pulmonary tissues. You want to treat the underlying cause and not the symptoms. But I have given Ventolin in the past to those patients and I am able to hear more crackles and wheezes post administration, isn t that a good thing?? You may hear more breath sounds but you are putting increase workload on a myocardium that is already stressed and lacking substrates, and are worsening the underlying cause.

44 CPAP AND PULMONARY edema. Severe pulmonary edema is a frequent cause of respiratory failure. CPAP increases FRC. CPAP increases transpulmonary pressure. Definition -The pressure difference across the lung. Alveolar pressure minus pleural pressure (Palv-Ppl), which is also known as the elastic recoil pressure of the lung. CPAP improves lung compliance. CPAP improves arterial blood oxygenation. CPAP redistributes extravascular lung water.

45 REDISTRIBUTION OF EXTRAVASCULAR LUNG WATER WITH PEEP. The application of PEEP to the edematous lung decreases intra-alveolar fluid volume, increases interstitial lung water, and facilitates the movement of water from the less compliant interstitial spaces where gas exchange occurs to the more compliant interstitial spaces. This redistribution of interstitial water improves oxygenation, lung compliance, and ventilation/perfusion matching when applied in either cardiogenic or non-cardiogenic pulmonary edema.

46 Asthma is a not COPD, therefore asthma exacerbations are NOT treated with CPAP. Why would this not be indicated for the asthmatic patient? Asthmatics have difficulties with exhalation and have air-trapping due to broncho-constriction and increased mucous production, using increased pressure may worsen their condition. They are at an increased risk of barotrauma. There is no need to recruit alveoli, they are full of air already.

47 CPAP AND ACUTE RESPIRATORY FAILURE. CPAP overcomes inspiratory work imposed by auto-peep. CPAP prevents airway collapse during exhalation and has the effect of splinting the airways CPAP improves arterial blood gas values. CPAP may avoid intubation and mechanical ventilation. (Miro 1993)

48 COMMON COMPLICATIONS ASSOCIATED WITH CPAP. 1. Pressure Sores - Since the advent of soft, self-sealing masks, these complications are usually limited to nasal-bridge pain and erythema at the site of application. However these symptoms can be reduced by the prior application of materials such as Granuflex. Another less serious complication of the mask is patient discomfort or intolerance. 2. Gastric Distension - The most significant potential complication cited by early critics were aerophagia and aspiration of gastric contents. However, the levels of CPAP used (<10 cm H 2O) are usually not associated with gastric distension. If this complication occurs, it is easily remedied by naso-gastric intubation, with regular aspiration. Gastric aspiration related to CPAP via face mask has never been reported in the literature. 3. Pulmonary Barotrauma - With mask CPAP, as with any positive-pressure therapy, the potential for distension and pulmonary barotrauma is always present. However, in investigations cited by Branson (1985) only one of 196 patients developed evidence of barotrauma (pneumomediastinum), representing a complication rate of 0.5%. The low incidence of barotrauma in these patients may be attributed to the use of spontaneous breathing as the method of ventilatory support. To further minimise this risk the patient should be encouraged to exhale completely while on CPAP. 4. Reduced Cardiac Output - Positive-pressure therapy has been associated with a decrease in cardiac output by Gong (1983). However, hemodynamic compromise in patients treated with the levels of CPAP described in that report was most often due to hypovolemia. In Branson s report cardiovascular depression did not occur in patients with adequate volume status. 5. Hypoventilation - A potentially lethal complication of mask CPAP is hypoventilation, which may occur with excessive levels of CPAP. Overdistension of normal lung units can increase the ratio of dead space to tidal volume and result in CO 2 retention. Hypoventilation may also occur in patients who become lethargic and weak. All patients receiving CPAP therapy should be closely monitored, and if CO 2 retention is identified, intubation and mechanical ventilation should be instituted.

49 6. Fluid Retention - The application of CPAP causes a reduction in urine output secondary to reduced renal perfusion, redistribution of renal blood flow and increased antidiuretic hormone secretion. It is often necessary to modify fluid therapy or employ diuretics when applying positive airway pressure if fluid retention and odema are to be avoided. Alternatively, the depression of cardiovascular and renal function which may occur with CPAP may be treated successfully with inotropic agents. 47

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61 CPAP must be continuous.

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