Category: CPAP

CPAP - "Alternative Treatments"

Question#: 565

Question:

In regards to the OBHG MAC Oct 19/21 Memorandum; Considerations for Paramedics Managing Patients during the COVID-19 Pandemic, what "alternative treatments" are they referring to under Part A: Point #3 CPAP Medical Directive which states: "Paramedics may withhold CPAP if alternative treatments are available/appropriate."

Answer:

CPAP is indicated for patients with severe respiratory distress and acute pulmonary edema (regardless of origin) or COPD.

The alternative treatments:
* COPD induced bronchoconstriction: supplemental oxygen and salbutamol by MDI.
* Acute cardiogenic pulmonary edema: supplemental oxygen and nitroglycerine.
* Other causes of acute pulmonary edema: supplemental oxygen.

Treatment considerations:
* Start with the alternative treatments while doing a risk assessment and, if appropriate, donning higher-level PPE in preparation for CPAP.
* Provide high-concentration oxygen by low-flow mask.
* Rather provide CPAP than nebulised salbutamol (contraindicated in declared febrile respiratory illness outbreaks) or assisting ventilations with BVM (in spontaneously breathing patient), as these are also aerosol generating activities but have lower effectiveness then CPAP.

OBHG-MAC COVID-19 recommendations:
* In 22-Feb-2021: Paramedics SHOULD consider, in all cases, WITHHOLDING CPAP.
* Currently, from19-Oct-2021: Paramedics MAY WITHHOLD CPAP if alternative treatments are available/appropriate
* This is a fundamental change in the expected treatment:
* Before the COVID pandemic: provide CPAP concurrently with salbutamol or nitroglycerine, where indicated.
* During the COVID pandemic, before 19 October: NOT provide CPAP, just use the alternative treatments.
* Currently: start with alternative treatments and move rapidly to CPAP if the patient is not improving.

Explanation of clinical decision required on the ACR:
* Before the COVID pandemic: if the patient did NOT receive CPAP.
* During the COVID pandemic, before 19 October: if the patient did receive CPAP.
* Currently, if the patient is started with CPAP rather than available other treatments, or does NOT receive CPAP despite no available treatments and/or no improvement.

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