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CPAP and administeration of oral medications

28 posts in this topic

Posted · Report post

I had a scenario the past week involving an exacerbation of emphysema which I decided to treat with Nebulized Ventolin through the CPAP mask along with Solumedrol. My instructor decided to introduce a new onset of Angina with Ishemic changes in leads II, III and aVF.

He asked me how I would treat the new onset of symptoms to which I replied I would administer 2.5mg of Morphine SIVP. He challeneged me to consider the administration of ASA and Nitro which would require me to remove the CPAP device.. I stood behind my decision to keep the CPAP device on my patient as the COPD exacerbation was the primary complaint, and there's also a risk to the patient in removing the mask once it is applied, and the angina is secondary and can be relived by the morphine.

Just curious as to what some other opinions of this would be?

Administration*

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Posted · Report post

With elevation in said leads, you had best do additional investigating before giving preload reducing agents such as nitroglycerine. Aspirin is absolutely needed assuming no contraindications.

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Posted · Report post

Yes, absolutley would be cautious in administering nitro to a patient with inferior wall ishemia, I would have done a right sided 12-lead to get some additional views prior.. I did not give ASA because of the risk/benefit of removing the CPAP device. To be completely honest, I don't really know if it is common practice to temporarly remove the mask to give oral medications.

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Posted · Report post

In the case of Aspirin, it's one of the only interventions available to us that actually decreases morbidity/mortality in these kinds of patients, so I think you could put up a strong argument for ASA use.

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Posted · Report post

To add to what CHBARE said, not only is ASA one of the only medications available to us to reduce morbitity and mortality, but there is some evidence to suggest that morphine makes it worse. Taking care of the pain does not end the ischemia, which is how I read your comment about angina being relieved by morphine. Morphine relieves the pain. It does not stop the damage.

Good question.

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Posted · Report post

Steph asked me this too. My response was that CPAP won't be removed long enough to cause any complications when one considers the benefits from the medication.

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Yeah, I could see it being argued both ways; however, I've read that ASA has its peak effects in 6 hours which makes the immediate administration of it go down on my priority list when contrasted with removing CPAP and introducing an oral medication to a patient who is a minutes away from crashing without the CPAP.

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Posted · Report post

hmmm. you sure about that peak time. Don't forget that onset is also important. Also. why do you need the CPAP in the first place? Could the respiratory problem be carcinogenic?

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Posted · Report post

Sorry, duration can be up to 6 hours, peak effects 15-120 minutes and onset 5-30 minutes.

Patient had perioral/peripheral cyanosis with R.R at 32 and 02 sats of 77%. I first started my patient on an NRB at 15lpm while auscaltating lung sounds which revealed wheezes in upper lobes with decreased to bases bilat, and no acoustic shadow or bloody sputum indicating mastocytoma/metastatic lung CA. Still quite possible though, the patient was 65 and a pack a day smoker. The patient didn't improve on 15lpm, and has history of COPD, home 02 x 5 years, I selected CPAP to try and increase the traction of the airways and decrease airway resistance by delivering 5mg ventolin through the CPAP nebulizer attachment.

Another reason I went with with CPAP is because if my patient did end up crashing and needed to be intubated, from what I've seen it is very hard to ween COPD patients off of the vent once they've been tubed.

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Posted · Report post

I asked a resp tech the question about removing cpap to administer oral meds. She said they do it all the time to administer nitro to CHFers. I was told the short amount of time it takes to do this won't harm them.

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Posted · Report post

Respiratory tech or respiratory therapist?

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With chbare on this topic, I feel nearly lnelligable to answer, but here you go:

The real question you pose is : Should CPAP be removed to administer oral medications?

First we must point out what CPAP is doing in layman's terms.

Continuous positive pressure in the incidece of COPD exacurbation is somewhat "splinting open" the airways by removing the negative pressure phase on inspiration.

The second mechansm is to re-recruit collapsed alveoli, again through positive pressure.

So, the question of removing the CPAP.

As we can see above, CPAP itself is a great temporizing measure to open up the airways, and allow better gas exchange. We must realize thoug that it is only a temporary fix. It can make a very sick patient appear well however if we do not fix the real problem (bronchospasm/secretions), then eventually the patient will decompensate...... or need CPAP for a very long time!

So you need to do a risk/benefit anaysis of your oral meds. By remoing the mask temporarily, some alveoli may re-collapse, the splinting of the airways will cease and the spasm will begin to dominate once again. That said, the speed in which this takes place will be patient dependant. However, if they die of an MI with no treatment, none of it will really matter!

This is the beauty of ALS, you post a clear cut question, and get no answer!!

I will always remove the mask to administer nitro/ASA/Plavix. For the few seconds it takes, even in full pulmonary edema, I have yet to find literature that supports continuous CPAP sans all other treatment.

Forgot to mention: Nitro drips and CPAP work nicely together fo Pulm edema!

I would do the same in this scenario. A spray or two, then start a drip.

If there was suspicion of a preload dependant blod pressure, I would (and have) forgone the spray, and just start low dose drip.

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Posted · Report post

Interesting thread. Just a question here for chbare or anyone who knows since we're talking CPAP and COPD. I had been under the impression that in COPD, the CPAP is basically counteracting the loss of radial traction and increased resistance (loss of positive transmural pressure) that has led to the bronchioles collapsing as the equal pressure point moves down below the cartilage supported airways.

Is there something going on with the alveoli specifically as well?

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This is the original 1988, ISIS-2 study. Streptokinase (the most widely-used thrombolytic at the time), versus ASA, versus ASA + Streptokinase, versus placebo.

http://www.ncbi.nlm.nih.gov/pubmed/2903874

Either streptokinase alone, or ASA alone, reduced the 5-week mortality by 25%. Given together, there was an even greater reduction.

From this, and later studies, came our current treatment options. As chbare said ASA is absolutely vital.

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Thanks for all of the responses guys.. Kind of interesting, because I was scoulded by my Pharm teacher for saying I would administer Nitro to a Pulm Edema q 5 minutes while temporarly removing the CPAP mask..

Mobey, I wish that we had Nitro IV on car, during the scenario I said I would give my Nitro either as a nitro patch or through IV infusion to minimize interruptions, but of course it was the program head evaluating me, so of course, he wanted a clear answer as to whether I would take the mask off or not.

After reading a few responses and doing some research, I think I just really have to change my thinking as to what is BEST for the patient, and if that ASA is what stops that ischemia from progressing to infarct, I can't stand here and say it would be the right thing to withold that treatment from the patient.

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I'm sorry, I meant respiratory therapist. I was exhausted and that was the third time I re wrote that post, I kept loosing it and I was getting angry.

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My concern with administering nitroglycerin to a patient on CPAP would be less about having to remove the mask (because once they have that mask on, they likely won't let you take it off them) so much as lowering their BP too much. In the few times I've used CPAP on a patient they had very drastic drops in their blood pressures. My last patient went from 199 systolic to 116 in 5 minutes. Not that I've ever seen nitro drop BP that much, but with those kinds of rapid changes I'd be cautious about controlling that blood pressure.

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Posted (edited) · Report post

Mobey, I wish that we had Nitro IV on car, during the scenario I said I would give my Nitro either as a nitro patch or through IV infusion to minimize interruptions, but of course it was the program head evaluating me, so of course, he wanted a clear answer as to whether I would take the mask off or not.

I liked making Duane's life difficult back in the day. I'd have stuck to my guns and said I'd administer nitro IV. There's no reason we can't if it's available...if he wants a response requiring you make the absolute choice whether or not to remove the mask....make him ask a question that forces you to make the choice. Then again, I pissed him off so badly that he ended up trying to kick me out of the program on a trumped up charge anyways so it might not be so wise to become a thorn in his side. :)

Edit:

Sequel...consider what you're saying regarding the drop in BP and the mechanism of action. Perhaps that reduced BP was the result of a physiological response by the body because it was returning to homeonormal status.

Edited by Arctickat
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Posted · Report post

Put the pills in a straw..pull hose off CPAP momentary..stick straw in mouth..and down she goes.

Patent pending! Ha!

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With a bit of coaching you can maintain CPAP's positive airway pressure during nitro admin:

Go through the nitro admin procedure with the pt before removing the mask. Unstrap it while holding it on the face manually. Remember you don't want the pt inhaling SL nitro, and you want the pt to lift their tongue to the roof of their mouth. So if you can coach the pt to hold their breath for a moment, put their tongue to the roof of their mouth, and then quickly take the mask off and spray, the pt's glottis should remain closed maintaining airway pressure - and airway splinting.

It's not perfect, and you need to be fast and have a compliant pt, but I've had a run of CPAP calls in the past 6 weeks and it seems to work.

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Posted (edited) · Report post

Excellent first post jkc, welcome to the City.

Edited by Arctickat
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Posted · Report post

So in cardiac scenarios today I was treating a patient for and acute MI with significant ST elevation in anterolateral leads with no relief of pain with rest of nitro. Gave him 3 mg Morphine SIVP and brought his pain from a 7/10 to a 4/10. This same instructor throws in that my patient has a 20 year history of asthma that he forgot to mention. Suddenly, the patient presents with a mild bronchospasm with audible wheezes. This increased his resp rate from 18-24 and drop his 02 sats from a 96 to a 92%...

The question was asked whether I would now treat with Ventolin... I first said I would switch my patient from a nasal at 3lpm to an NRB at 15 lpm and see how my patient tolerated it and whether the histamine relased by the morphine would resolve in a few minutes...My main reasons for not giving ventolin to an AMI patient was because I wanted the heart to have to work as little as possible, and the beta 1 properties of ventolin would increase peripheral vascular resistance and increase heart rate, potentially causing more damage to the myocardial tissues.

Thoughts? I'm still not sold on administering a drug with beta 1 agonist properties to a new onset, unresponsive to nitro, unstable chest pain.

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Posted · Report post

Great question Jack. Have you checked your protocols? ;) Specifically CP2.

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Thanks Arctickat. I can't take credit, though, that tip was passed on by an excellent college instructor.

J306, as far as briefly removing CPAP and patient compliance with CPAP, all my recent CHF calls have required intensive efforts to get the patient to keep the mask ON. It's quite uncomfortable, and I can understand why patients feel the large CPAP arrangement (filter, ETCO2, Boussignac valve, facemask, headstraps) is even more smothering than an NRB can seem to some anxious, hypoxic patient. Not to mention the unaccustomed positive pressure itself.

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Great question Jack. Have you checked your protocols? ;) Specifically CP2.

Sure did, even quoted it in my scenario, to which the response was that it was contraindicated in Pulmonary Edema not in AMI... Two intructors have now said that since it was under the Pulmonary Edema protocol it does not apply to the CP1 protocol... Interesting.. I'm still not convinced, but regardless, my thoughts are that we should be striving to "do no harm" so it all comes down to the greatest benefit to the patient.

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