EMS in Focus
by Dean Meenach
11/01/2013

Expanding the pre-hospital use of CPAP in pediatrics


Continuous Positive Air Pressure (CPAP) has become a valued therapy for an array of adult respiratory and cardiopulmonary emergencies in the prehospital setting. Prehospital consideration for CPAP is rapidly gaining acceptance for another unique patient population — pediatrics. EMS providers contribute to the growing body of evidence by supporting development of patient care protocols that clearly identify the role of CPAP in emergency care.

Basic Concepts

CPAP provides positive pressure to help a child breathe during the respiratory cycle. Positive intrapulmonary pressure is applied artificially to the airways, which keeps the alveoli open or reopens collapsed/unstable alveoli leading to improved oxygenation and ventilation. CPAP is not a ventilator, but it allows the struggling child to convert rapid little “fish puffs” into fuller breaths with improved gas exchange.

Clinical applications

The efficacy of CPAP in treating a variety of pediatric illnesses associated with respiratory distress is demonstrated in the literature (Deis et al., 2008).

Bronchiolitis: The benefit of CPAP in treating bronchiolitis remains unclear. One large study showed that even with the use of medications, IV fluid hydration and CPAP, only oxygen was of proven benefit (Unger, et al., 2008). Other studies have demonstrated the success of CPAP compared to intubation in treating respiratory failure associated with some types of bronchiolitis (Javouhey, et al., 2008 and Cosentini, et al., 2010).

Pneumonia: Oxygen and CO2 are unable to pass freely through the alveolar-capillary membrane when pneumonia and other infections result in ventilatory fatigue, hypoventilation, bronchial inflammation, small airway collapse, and mucous plugging. It is suggested that CPAP helps increase lower airway resistance and relieves fatigued inspiratory muscles to restore tidal volume.

Asthma: The pathologic features of asthma include bronchoconstriction, bronchial edema and mucus plugging caused by excessive secretion of thick mucus. This can result in hypoxemia and hypocapnia. CPAP forces the small bronchioles open and allows for trapped air to be released from the alveoli. Additionally, modern CPAP systems allow for continuous administration of nebulized bronchodilators that are often indicated in the treatment of asthma and pneumonia.

Pulmonary edema: Pulmonary edema in a pediatric patient is usually rare and noncardiac in nature. Complications from toxic inhalation and carbon monoxide inhalation can result in noncardiac pulmonary edema. In moderate to severe CO poisoning, there is a 10 — 30% complication rate of pulmonary edema (Bartlett, 2006). CPAP may assist in fully oxygenating hemoglobin improving the hypoxemia caused by the hyper-soluble carbon monoxide (Jones, 2002).

Drowning: The use of CPAP may be considered in the management of submersion injuries. Patients suffering from near-drowning in freshwater have pulmonary injuries that are associated with atelectasis and hypoxia.

Pediatric victims of saltwater near-drowning are more likely to develop pulmonary edema as the aspirated hypertonic solution pulls plasma into the alveolar cavity.

The positive pressure ventilation achieved by CPAP may improve oxygenation in both fresh water and salt water drowning patients who are awake and spontaneously breathing (Dottorini, et al, 1996 and Gonzalez-Rothi, 1987).

Monitoring CPAP effectiveness

Pediatric CPAP monitoring should include continuous cardiac monitoring, end-tidal CO2 and pulse oximetry, and frequent assessments of lung sounds, worsening gastric distension and temperature monitoring if available.

Signs of patient improvement during CPAP include the following:

  • improving skin color, mental status
  • improving respiratory tidal volume, lung sounds
  • decreasing respiratory rate, accessory muscle use and retractions
  • decreasing anxiety or agitation
  • a normalizing heart rate

How-to basics

When providing CPAP in pediatric patients, start with low pressures (5 cm H2O). Increase it in increments of 1 cm H2O, as tolerated by the patient.

The recommended maximum CPAP should be 15 cm H2O for patients less than 12 years of age. For patients 12 years and up, the maximum should be 20 cm H2O. 20 cm H2O in patients 12 years and up.

  • Use age-appropriate communication to explain the procedure to the patient.
  • Ensure adequate oxygen supply to the ventilation device.
  • Initiate continuous monitoring devices.
  • Place the delivery device over the mouth and nose.
  • Secure the fitted mask with the appropriate securing devices.
  • Start with 5.0 cm H2O of PEEP pressure may be titrated up to 20 cm H2O as needed.
  • Check for air leaks.
  • Be prepared to coach the patient to keep the mask in place and readjust the mask seal as needed.

Summary

CPAP has been accepted as a valued prehospital therapy for treating common causes of pediatric respiratory distress caused by asthma, bronchiolitis and pneumonia. It is noninvasive, adaptable for all age groups and can be initiated quickly and easily in the field. By embracing evidence-based protocols and close patient monitoring, EMS professionals will make a significant contribution to the expanded use of prehospital CPAP in the pediatric population.

References

Bartlett D. (2006). The Great imitator: Understanding & treating carbon monoxide poisoning. Lethal Exposure. Elsevier Public Safety.

Cosentini R, Brambilla AM, Aliberti S, et al. Helmet continuous positive airway pressure vs. oxygen therapy to improve oxygenation in community-acquired pneumonia: A randomized, controlled trial. Chest. 2010;138:114–120.

Deis JN, Abramo TJ, Crawley L. Noninvasive respiratory support. Pediatr Emerg Care. 2008;24:331–338.

Dottorini M, Eslami A, Baglioni S, et al. Nasal-continuous positive airway pressure in the treatment of near-drowning in freshwater. Chest. 1996;110:1122–1124.

Gonzalez-Rothi RJ. Near drowning: Consensus and controversies in pulmonary and cerebral resuscitation. Heart Lung. 1987;16:474–482.

Javouhey E, Barats A, Richard N, et al. Non-invasive ventilation as primary ventilatory support for infants with severe bronchiolitis. Intensive Care Med. 2008;34:1608–1614.

Jones A, Recent Advances in the Management of Poisoning. Ther Drug Monit 2002;24:150-155

Unger S, Cunningham S. Effect of oxygen supplementation on length of stay for infants hospitalized with acute viral bronchiolitis. Pediatrics. Mar 2008;121(3):470-5.

Dean Meenach, RN, BSN, CEN, CCRN, CPEN, EMT-P has taught and worked in EMS for more than 20 years and currently serves as Director of EMS Education/Paramedic Instructor and co-teacher in the Paramedic to RN Bridge Program at Mineral Area College. He has served as a subject matter expert, author, national speaker, and collaborative author in micro-simulation programs. Dean continues to serve patients part time as a member of a stroke team and in a pediatric and adult trauma center. He can be reached at dmeenach@mineralarea.edu.

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