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July 1, 2011

The basics of CPAP

Every now and then a technology comes to our profession that dramatically changes the way we manage a medical emergency. One such tool that is rapidly gaining widespread acceptance in our industry is continuous positive airway pressure, or CPAP. Highly effective for patients in respiratory distress secondary to congestive heart failure or reactive airway disease, CPAP is easy to understand and even easier to deliver.

The Way We Breathe
We breathe for gas exchange. It sounds funny, but it's true. Your body relies on a continuous flow of oxygen in, and the flow of carbon dioxide out, in order to operate effectively. To do so, we rely on air pressure and the mechanics of breathing to make that happen in the alveolus, the functional unit of the lung.

An alveolus is a very small structure with a large amount of surface area, allowing gases to diffuse through it efficiently. The millions of alveolus we have in our lungs are called alveoli. Because of inherent moisture in the wall, surface tension builds that would collapse the alveoli if it weren't for the atmospheric pressure inside the lung and a liquid that reduces surface tension, called pulmonary surfactant.

To make air move, the diaphragm and the accessory muscles in the chest contract, causing the chest cavity to enlarge. This causes the pressure inside the lungs to drop and become negative in relation to the atmosphere, allowing air to passively flow in as we inhale. Upon expiration, the same muscles relax, causing the chest to shrink in volume. This causes the pressure to rise inside the chest, forcing air out of the lungs.

Air moves in and out of the alveoli through a series of tubes called bronchioles. These tubes are like the roots of a tree, combining together and becoming larger in diameter. The two largest tubes are called bronchi and they meet together at the carina. From there, the air moves out of the lower airway through the trachea and is eventually released into the atmosphere through the upper airway.

What Can Go Wrong
As simple as it sounds, our ability to ventilate is in fact a very complex system. There are many points where the system can be compromised or fail. The tissue surrounding the alveoli can become congested with fluid, a condition known as pulmonary edema. This makes it harder for gases to pass through the aveolar-capillary membrane, and it creates undue pressure on the alveoli, resulting in causing them to potentially collapse (atelectasis).

Another example is where the bronchioles become irritated due to exposure to things like pollen, causing them to inflame and swell, reducing the diameter of the tubes. This makes it harder for airflow to occur; the wheezing you hear upon auscultation during an asthma attack is the sound made as air moves through the constricted bronchioles. In addition, excessive mucous is produced, which clog the bronchioles even further. Long-term lung diseases such as emphysema and chronic bronchitis can flare up, or exacerbate, causing acute shortness of breath.

How CPAP Works
As the name suggests CPAP generates a gentle amount of extra air pressure inside the lungs during inhalation and — especially — during exhalation. You can roughly imagine this by taking a balloon and blowing it up until it's full. If you were to breathe through your nose while keeping the balloon opening in your mouth, you would start to feel pressure from the balloon building into your mouth.

CPAP works the same way — a circuit creates extra pressure at the end of the patient's exhalation phase, keeping the bronchioles and alveoli open. The pressure isn't much — about 5 — 10 cm of water pressure is all that's necessary. In pulmonary edema, this pressure forces the excess fluid to leave the interstitial tissue surrounding the alveoli, allowing better exchange of gases. The bronchioles also increase in diameter, promoting better airflow down to the alveoli.

In order for CPAP to work, there must be a pressure-tight seal throughout the system. CPAP accomplishes this with a well-fitted mask that the patient wears over the mouth and nose. The circuit is attached to the mask and the patient is encouraged to breathe as normally as possible. Many patients will begin to feel relief within seconds to minutes of application, as their lungs begin to exchange gases more easily. Many providers report that the change in their patient's condition is so dramatic that they have to convince hospital staff of the original severity level!

There are a few precautions. The main concern is that CPAP can, and will, lower blood pressure. This makes sense: as pressure increases inside the lungs, it also increases pressure on the heart chambers and great vessels, causing cardiac output to drop. If the patient is hypotensive to begin with — i.e. the patient is experiencing cardiogenic shock with pulmonary edema — CPAP is not indicated. The patient must also be breathing and able to follow commands in order for CPAP to work effectively.

There are many devices available for prehospital CPAP use such as the O2-RESQ or the PortO2Vent. While it remains primarily an ALS procedure, states like Wisconsin, Tennessee, Oklahoma and others that authorize CPAP at the BLS level. It is an easy technology to understand and implement, and it can be a real benefit to patients with difficulty breathing.

About the Author

Art Hsieh, MA, NRP teaches in Northern California at the Public Safety Training Center, Santa Rosa Junior College in the Emergency Care Program. An EMS provider since 1982, Art has served as a line medic, supervisor and chief officer in the private, third service and fire-based EMS. He has directed both primary and EMS continuing education programs. Art is a textbook writer, author of "EMT Exam for Dummies," has presented at conferences nationwide and continues to provide direct patient care regularly. Art is a member of the EMS1 Editorial Advisory Board. Contact Art at and connect with him on Facebook or Twitter.