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Pulmonary Fibrosis and use of CPAP

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Posted · Report post

So without ridiculing, I'm really curious.

Case:
90 something from a nursing home. Get limited info from staff for obvious reasons. Pt presents in bed very obviously tachypneic and using accessory muscles. Pt obviously severely dyspneic. Pt CAO x 3. Just states she can't breath. Unknown onset. Pt on O2 @ 5 lpm via NC with SaO2 96%. Normally on 2 lpm per staff. Pt has PMH of HTN, NIDDM, and pulmonary fibrosis. Possibly has part of a lung removed but it is unknown which or how much was removed. BP was around 98/60. Weight 80lbs soaking wet. Lungs were actually clear as est I could hear. And they were present throughout just slightly diminished on the right, so they probably removed the right base. Any other pertinent info that I'm missing here, just ask.

Anyway, she's a DNR, definitely no tubes. Pt put on HF O2. Blood sugar 212 mg/dL. ETA of only 2 minutes from local nursing home to hospital, it's right around the corner.

Another medic saw me and immediately inquired why I didn't use CPAP.

Couple questions here.
1./ What exactly is Pulmonary Fibrosis?
I was under the impression it was a disease that basically caused the lungs to harden and have difficulty expanding.

2./ If I used CPAP (not BiPAP), wouldn't that just cause a build up of pressure? This, in my mind, would have led to a probable pneumothorax.

I don't think, short of bagging her or intubating her, I could've done much else. But she was a DNR so I couldn't do that. Plus being such a short transport, I opted to just run. But if it was longer, would CPAP have been a good idea to use?

Any help is greatly appreciated. I'm still learning, I admit it!! lol
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Posted · Report post

Here is some info on Pulmonary Fibrosis

[web:e4d2a09bf4]http://www.pulmonaryfibrosis.org/ipf.htm[/web:e4d2a09bf4]

As far a using CPAP I dont know
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Posted · Report post

CPAP would have delayed definitive treatment and could have further depressed her BP. You still had good SpO2 with relatively low FiO2 although her Hb may have been very low giving you a skewed view of oxygenation. 5 L NC is still low O2. Placing the pt on a high flow mask would have given you more Fi02. Remember when a pt is breathing rapid or moving large volumes per minute they are entraining more RA at 21% and diluting the amount of oxygen actually taken in. You think you're giving about 35% by NC when actually it might be 24% that is actually being inspired.

An IV should be present in case of BP problems...more time. Also, what type pressors or fluids will be needed to maintain adequate BP. I have seen CPAP at 5 cm H2O totally bottom a BP on a compromised pt.

Also, you might check with your medical director for a clarification for starting CPAP on a DNR. A pt in a nursing home may also have comfort care orders along with that DNR...different but similar to hospice. Once breathing technology is started, ER docs usually don't want to remove it. Then, it can become an ethical issue in some hospitals.

A trial of higher concentration of O2 will be done in the hospital while fluids and steroids are given along with a trial of bronchodilators if they have a mixed component lung condition. Hospitals also have high flow NCs that can go up to 25 - 40 l/m to offset the dyspnea while providing a more comfortable alternative.

If the patient is comfortable on that, they can express their wishes for more technology like CPAP or future therapy. If the pt goes to the med surg floors, CPAP used in hospitals may not be able to go with them. JCAHO standards require certain levels of monitoring unless it is a home CPAP machine. If the pt requires more O2 than prescribed for their home unit, they go on the hospital's machine and on to a monitored unit. Of course, DNR does not mean do not treat. If the immediate condition is reversible and warrants it, CPAP/BIPAP will be used and the pt will be placed in ICU or a monitored step-down unit.

If the pt is end stage; CPAP is a hard way to go. They will have limited communication and will be NPO. The mask is hot and tight which will cause breakdown and skin tears, esp on a PF pt who has probably done a lot of steroids. In the ER or ICU they may be tied down to keep them from pulling off the mask once it is decided to keep the CPAP on.

There are also about 200 known diseases including some medications that lead to Pulomonary Fibrosis.
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Posted · Report post

Yes must agree with everthing Ventmedic stated, my preference would be BIPAP over CPAP as CPAP can increase Work of Breathing, but watch the BP to be sure.

In most cases in PF these are mixed restrictive and obstuctive disorder's so bronchcdilation may not be a bad idea.

In some cases severe Dyspnea can be relieved with nebulized morphine, and if this patient is end stage I can't see why this would not be another option as well.

cheers
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Posted · Report post

Thanks guys/gals.

Vent - I did exchange the nasal for a NRB @ 15 lpm, thought I said that. Sorry if I missed that. And we did attempt IV sticks enroute but between the prednisone skin, and veins, they were unsuccessful. I have also had pt's bottom out after CPAP use, so I was leary in this case. We don't have the option of BiPAP so it was CPAP or nothing, I chose the later. Thanks again for your imput.
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Posted · Report post

You did what you could without causing further complications.

Pulmonary fibrosis is an aveolar wall inflammation causing the lungs to become fibrotic. The cause can be organic or inorganic. Lung volumes and diffusing capacities are periodically checked in a pulmonary function lab if on certain meds; bleomycin, cyclophosphamide, methotrexate and amiodarone. Endstage CXRs will look like a honeycomb. Lungs will become stiff as lung compliance is lost. Overall lung volumes will decrease. The ability to diffuse oxygen is reduced thus ventilation-perfusion mismatching. Lungs may sound clear. Air will move through the airways but will be unable to diffuse into the blood stream due to the aveolar damage. This will lead to hypoxemia at rest with little relief from outside therapies eventually.

If I ever reached end stage with a breathing disorder; high flow nasal cannula (Vapotherm) so I can have my martini with some vodka on the side to nebulize if pulmonary edema happens and nebulized morphine with matching IV doses.

cheers
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Posted · Report post

HAHA. Great ending.

Thank you for the in depth reply. I appreciate.

So, judging from your post, it is safe to assume CPAP would have probably caused more harm than good which was why I avoided it. Even if I was questioned, I would still stand by my decision. But thank you, it seems to clear it up for me a little.
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Posted · Report post

[quote name='VentMedic']If I ever reached end stage with a breathing disorder; high flow nasal cannula (Vapotherm) so I can have my martini with some vodka on the side to nebulize if pulmonary edema happens and nebulized morphine with matching IV doses.

cheers[/quote]

Hey thats my line...damn RTs anyways.... :lol:

Late entry, we are seeing a new population of PF ers rearing its ugly head lately, I did not see mentioned in this discuss "TALC LUNG" another mixed disorder, I doubt your patient would fall into this etiology but for just for completeness. The long term use of amiodarone is often over looked an excellent inclusion Ventmedic for those gathering good med history (s)

CHEERS
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Posted · Report post

Does amio cause it or they're usually on it?? Never took notice to that before, although this one was not on it.
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Posted · Report post

[b]
Long term oral doses.[/b]


Pulmonary Toxicity
"Pulmonary toxicity is perhaps the most feared adverse effect of amiodarone. Initial estimates of its frequency ranged from 2% to 17%, with fatalities occurring in 10% of affected patients10- 18; however, more recent estimates in patients receiving daily doses of 400 mg or less indicate an incidence of no more than 2%.19,20 Pulmonary toxicity presents as either interstitial pneumonitis or hypersensitivity pneumonitis. Interstitial pneumonitis is the most common presentation, accounting for two thirds of amiodarone's pulmonary toxicity,11 and hypersensitivity pneumonitis accounts for the rest.16"

Full article at;
[url="http://www.continuingeducation.com/pharmacy/amiodarone/adverse.html"]http://www.continuingeducation.com/pharmac...ne/adverse.html[/url]

[url="http://www.continuingeducation.com/pharmacy/amiodarone/"]http://www.continuingeducation.com/pharmacy/amiodarone/[/url]

More on PF on eMedicine
[url="http://www.emedicine.com/MED/topic1960.htm"]http://www.emedicine.com/MED/topic1960.htm[/url]
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Posted · Report post

scratrat:

Amiodarone (long term usage) can lead to PF complications, the PFTs that Ventmedic is refering are called DLCO (diffusion limited carbon monoxide testing) always wondered how good that test was for the patient?

TALC Lung a completly different story, IV drug abusers with bad "cuts" from those concerned "dealers" that use talcum (sp) powder is used and with devistating results, as the lungs are an excellent "filters" The CXRays are "signature" as they look like a freakin snowstorm. I doubt in this 90 year old patient that this was tangible possibility.......that said.... I have come to the conclusion that one should "expect the unexpected".


cheers
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Posted · Report post

I don't know about the long term effects of DLCO. For the patients, they may only get checked once or twice/yr. The RTs in PFT lab have to keep their machines in cal and do frequent staff normals. My COHb will go up to 3.0+ after 4 checks on myself to do a staff normal. Other worries for RTs and PF/other; long term exposure to pentamidine, ribavirin, various antibiotics, nitric oxide (esp at 50+ ppm), flolan, other nebulized Prostacyclins, morphine and of course the old standards; albuterol, mucomyst etc.

We take precautions to keep nurses and family from being exposed. We are always telling the nurse to sit further away from the pt or keep the isolation door closed for his/her own safety when we're running these drugs in the ICU.

For the EMS teams, I will always voice my concerns for them when they do interfacility transports with some of the above drugs running on the pt. Precautions must be observed especially in close quarters.

In the 80s, when doing 24 pentamidines 3x/wk, I was checked by spirometry weekly. I was younger then.....
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Posted · Report post

Ventmedic:

I SOO hear you!

I got sick myself was on BIPAP for 3 days in 94 in my own IC, P02sa of 48, on 10 of PEEP, and Fio2 of 1.0 for 36 hours.
NOT fun times, a mycoplasma pneumonia (maybe?) so I wonder where I picked that up....fishing?
I couldn't work for 2 months. Let me tell you that just trying to get even short term disability was a freaken nightmare, no compensation at all, the MDs said it was pointless even applying for Workmans Comp. So many times the RTs are the forgotten as the very "Hi risk exposed" health providers (s) SARs was another example too.

But, I think you forgot one situation....CT Scan. NO mr. RT, the radiation is low level.....like 3 times a shift?
Ok then, why are you (mr/ms Xray) dude standing behind leaded glass, 4 inches forking thick!
I always asked where is my Lead Hat? but the Xray folks thought I was joking...sheesh. In case you ask it took 3 years to get a transport Vent in ER, and most RTs (at that time) said it was not worth the time in set up, TILL one died of a Brain Tumor!

sorry off topic Dean, but please [b]heed Ventmedics cautions ALL[/b], RTs are NOT just Oxygen boys.
cheers
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Posted · Report post

Sorry to hear you had to experience this first hand. At least you now can give a first hand account of CPAP vs BIPAP.
Impressive settings...

For Peds ER we have strict policy when giving nebs to kids...5 ft rule/mask. Pertussis got a couple of our staff one year. They too couldn't collect benefits.

I remember being so concerned while working in PICU about mycoplasma that the nurses and RTs were drawing each others blood to check for it. We had two kids on vents with it.

r/o TB; guilty until proven innocent.

I worked in NICU with 10 - 20 morning xrays...scatter. I hated to see our rad badge readings each month.

Now I occasionally do bronchoscopies...4 - 5 / day with flouro. I really look forward to the pulmonologist having a resident with him/her to learn the forceps.

As I get older, MRI transports don't appeal to me either if the vent isn't in service.

Thank goodness for students and nurses :lol:

Back to CPAP and different pulmonary diseases; Sometimes we have to re-educate the ER physicians what CPAP/BIPAP is used for and its limitations. Like Albuterol, it is sometimes thought of as the universal cure-all.

I have not examined too many prehospital CPAP machines so maybe you could help me out on this one.
With the hospitals' Respironics Vision (love this machine), the higher you go on FiO2 the lower the flow curve. Are the prehospital machines essentially flow generators with a manual PEEP valve?
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Posted · Report post

VENTMEDIC :

Again, thanks for the great posts.

I am not sure how many different devices there are for pre-hospital use. I can tell you I've used two different types. Both were CPAP though and not BiPAP.

1./ Had a set valve to deliver 10 mmHg PEEP and always delivered 100% FiO2.

2./ Can set anywhere from 0-?? mmHG PEEP. We are instructed not to exceed 10. Also, you can adjust the FiO2 from 0-100%.

I guess it's all medical director dependant.
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Posted · Report post

scratrat,
Thanks for the info.

One more question if you don't mind...

How long on average do you or your co-workers usually take to set-up CPAP on a pt? Is the head gear usually with the mask as a complete set?
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Posted · Report post

Shouldn't take any longer than 2-3 minutes start to finish. The ones' I've dealt with anyway. You basically have the power device that plugs directly into the wall of the ambulance, the tube goingfrom the device to the pt, the mask, a PEEP valve that goes on the mask, or some don't have that valve if it's an adjustable machine, and then the strap. That's all there is to it.

I recently moved down south and have been presented with a new device. I have never used it yet in the field, but I have put in together in training. The one I had up where I used to work, I could put that together in under 2 minutes.
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