Don’t you hate when two regulatory bodies (both in the same country, underwriting the same profession) can’t get along?
I do. It’s confusing.
And it’s all over a little CPAP (or no CPAP as the case may be).
I’ll start at the beginning: CPAP (Continuous Positive Airway Pressure) is a treatment method for various forms of respiratory distress and disorders.
The apparatus is a highly attractive accessory looking something like this……
The CPAP machine delivers a constant flow of air through tubing and a mask and into your airway. The CPAP machine creates enough pressure in your airway to hold the tissue open, so your airway doesn’t collapse. 1 It can be titrated for effect. The improvement seen following CPAP administration most likely occurs through a combination of 1) decreased work of breathing and reduction of fatigue; 2) recruitment of alveoli and improved oxygenation; and 3) splinting of larger airways, bronchiolar and bronchial to reduce airway collapse and mucous plugging. 2
CPAP is the main treatment for obstructive sleep apnea. Obstructive sleep apnea means you have short pauses in your breathing when you sleep. These breathing pauses – called apneas or apnea events – last for 10 to 30 seconds, maybe longer. People with obstructive sleep apnea can stop breathing dozens or hundreds of times each night. 3 People with sleep apnea will use their personal machine at home while (you guessed it) sleeping. CPAP is also useful in scenarios such as CHF (congestive heart failure), COPD (chronic obstructive pulmonary disease), and pulmonary edema.
When we were kids my cousin used to have to use a CPAP machine while he slept. He had some pretty terrible juvenile asthma (which thankfully he grew out of). I thought sleepovers at his house were a bit creepy. 😀
So there you have it, my first personal encounter with CPAP was as a treatment for asthma. You can imagine my surprise when studying in PCP school I learned that asthma is a contra-indication for CPAP in the emergency setting (in Ontario protocols).
The reason, as stated by the Southwest Ontario Region Base Hospital Program Manual, is this-
“The use of CPAP for acute asthma has not been well documented in the pre-hospital setting. CPAP in the treatment of an asthma attack may cause increased air trapping and increased intra thoracic pressure, or irritation of the bronchioles further pontentiating signs and symptoms. A patient suffering from asthma is in need of treatment with Salbutamol or Epinephrine depending on severity and treatment should not be delayed. As such, CPAP is not indicated for asthma, and is absolutely contraindicated in the presence of asthma exacerbation.”4
So that is what I believed. CPAP in emergent asthma will potentially make things worse (although we aren’t really sure because no one’s really studied it). Ok fine. We have other, better, treatments anyways (in Ontario).
But then I moved to Saskatchewan.
My SCOP protocols state that asthma is an indication for the use of CPAP. Ok, now I’m just uncomfortable! I just finished learning that applying CPAP to my asthmatic patients could make things worse, but now I’m supposed to do it?? That’s it- show me the studies!
Again I started asking questions, this time to my regional manager. According to him, the potential for air trapping caused by CPAP is outweighed by the patient’s likeness of moving into respiratory failure without it. Ah- a good point. CPAP could even prevent patients from needing intubation if initiated early enough. Which is good! According to JEMS, “In asthma, intubation rarely treats the primary problem, which is bronchial and bronchiolar in nature. Intubation is usually only indicated to provide relief for profound fatigue with secondary respiratory failure. Issues and concerns with intubation in these patients are obviated with the use of CPAP. Thus, CPAP has allowed us to reduce intubation in all types of acute respiratory disease by two-thirds or more.” 5
Furthermore, as an EMT in Saskatchewan I do not have the authority to use bronchodilators for respiratory distress outside of a patient’s personal prescription (sadly, no epi, no ventolin, no nebs). So basically, my only offline choice beyond regular 02 delivery is CPAP. So I’m going to use it (take that Ontario!)….and also be prepared to manually ventilate in case it doesn’t work.
My final thoughts….
1. Ontario Base Hospitals- Why don’t you look at Saskatchewan’s prehospital studies of CPAP use in asthma? If you are nice they might let you look at their PCR’s.
2. SCOP- Please let your EMTs administer Epi, Ventolin, nebs for respiratory issues. Alberta is laughing at you.
3. Canada…national regulation is long overdue.
4. I think I’m going to start my own private CPAP study because sometimes you just don’t know who to trust.