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CPAP and Pneumonia
Question# 972
As an ACP student, I am looking for clarification on the use of CPAP for severe respiratory distress when the etiology is clearly non-cardiac (severe pneumonia).
If my clinical assessment confirms the patient has the hemodynamic reserve to tolerate PEEP, but the presentation falls outside the "Acute Cardiogenic Pulmonary Edema" directive, is a patch required for a verbal order, or is there room for clinical judgement to initiate CPAP only therapy in these cases?
If my clinical assessment confirms the patient has the hemodynamic reserve to tolerate PEEP, but the presentation falls outside the "Acute Cardiogenic Pulmonary Edema" directive, is a patch required for a verbal order, or is there room for clinical judgement to initiate CPAP only therapy in these cases?
Answer:
For your reference, we have previously published a similar version of your question. It can be accessed https://www.rppeo.ca/paramedic-practice/medicask-about/medicask-answers-list/250-medical-directives/260-cpap/1923-cpap-use-with-pneumonia?highlight=WyJwbmV1bW9uaWEiXQ==
Having said that, we’d like to provide you with some additional notes regarding CPAP use in pneumonia as a learning summary:
In summary, if the patient meets the directive (concern for pulmonary edema or COPD with respiratory failure) and has no contraindications, then proceeding with CPAP is reasonable. If there are any clinical concerns or possible deviations, contact BHP on call similarly to any other case where the clinical picture is muddied.
Having said that, we’d like to provide you with some additional notes regarding CPAP use in pneumonia as a learning summary:
- The main concern for patients with pneumonia is the congestion in their lungs and blocking expulsion of sputum resulting in theoretical complication / organizing infection. In patients with severe pneumonia and respiratory fatigue, it is highly likely that they may meet sepsis criteria with hemodynamic compromise. As such, the positive pressure decreases your preload and therefore drops your blood pressure leading to a more peri-arrest scenario.
- Keep a close eye on perfusion and blood pressure as a marker of the adequacy of cardiac output in the context of the added intrathoracic pressure and during titration of CPAP pressures. In case of evidence of significant worsening cardiac output consider decreasing the pressures or discontinuing CPAP use.
- Typical therapy for individuals with pneumonia is up-titrating O2 therapy in an incremental fashion. Sometimes, very little oxygen is required to boost patients into the normal range for SpO2 readings. Starting with nasal prongs and escalating to a non-rebreather is reasonable to start. When patients begin to fatigue, it is secondary to ++ accessory muscle use over a prolonged period of time (or even a shorter time in the elderly). This is where positive pressure ventilation (CPAP or BiPAP) come into play which can help splint open the airway and reduce work of breathing. This is frequently used as a bridge to prevent or delay intubation especially in the elderly.
- Crackles in the lungs is nonspecific to pulmonary edema where unilateral crackles is more suggestive of pneumonia. Keep in mind the differential diagnosis including CHF, COPD (associated wheezing typically), pneumonia (bacterial or viral), etc.
In summary, if the patient meets the directive (concern for pulmonary edema or COPD with respiratory failure) and has no contraindications, then proceeding with CPAP is reasonable. If there are any clinical concerns or possible deviations, contact BHP on call similarly to any other case where the clinical picture is muddied.