An accurate assessment maximizes CPAP's effectiveness

By Kenny Navarro

Arguably, airway management is one of the most important interventions provided by emergency medical service personnel. Despite the allegiance to endotracheal intubation as a gold standard of airway control, endotracheal tube placement during acute exacerbation of various respiratory conditions comes with a significant increase in complications and mortality (Keenan, Sinuff, Cook, & Hill, 2004). Alternative airway control strategies such as non-invasive positive-pressure ventilation (NPPV) may be beneficial in some cases.

Two different types of NPPV are currently available. Bilevel positive airway pressure (BiPAP) increases the pressure during inspiration and decreases it during expiration. Continuous positive airway pressure (CPAP) provides a constant level of positive pressure during inspiration and expiration.

CPAP reduces the work of breathing, reinflates collapsed alveoli and improves pulmonary compliance. CPAP provides additional benefits to patients suffering from the acute effects of cardiogenic pulmonary edema by reducing both the preload and afterload, thereby improving the body’s hemodynamics.

CPAP reduces intubation risk in the ED setting

In 1998, a systematic review of emergency department (ED) administered CPAP via face mask found a 26% absolute risk difference in the need for intubation while caring for patients suffering from cardiogenic pulmonary edema with respiratory distress compared to standard therapy alone (Pang, Keenan, Cook, & Sibbald, 1998). A follow-up review conducted in 2006 found that ED personnel utilizing non-invasive positive pressure ventilation (NPPV) could decrease the relative risk of mortality by 39% while simultaneously decreasing the need for endotracheal intubation by 57% in patients with similar signs and symptoms (Collins et al., 2006). To date, there is no strong evidence demonstrating the superiority of one strategy over the other.