Don`t Put That Tube In!

     Attack One responds to a call for a person who can't breathe. A concerned husband meets the crew at his house's front door. His wife sits in the back bedroom in severe distress—they can hear her breathing from the porch.

     The crew quickly moves to the patient, the lead paramedic carrying the airway bag and taking the position closest to her. The woman is sitting upright in a chair, eyes closed, and at first seems unable to speak. In that position, the paramedic notes, the patient is diaphoretic, breathing rapidly and noisily, and has distended neck veins and edema in her feet. They ask her if she's having pain, but she doesn't respond.

     The paramedic touches the woman to begin assessment, and her eyes open briefly. The crew places a pulse oximeter on her finger and checks a quick blood pressure. Her oxygen saturation is in the high 60% range, pulse rate regular and rapid. An oxygen mask is applied at high flow. The paramedic opens the airway kit, preparing for endotracheal intubation, while her partner applies the cardiac monitor. "You going through the nose or the mouth?" he asks.

     The patient opens her eyes and mouths a few syllables they can't hear. They ask her to repeat what she said; again the response is inaudible.

     Her husband speaks up: "She's saying 'No tube'!"

     The crew looks up at him. "Don't put the tube in," he reiterates. "She's been on the machine before, and she doesn't want that ever again. The tube means the machine, and neither of us will agree to that. Don't put the tube in."

     That makes it fairly clear.

     The oxygen has improved the patient's saturation to the low 70s, but her distress hasn't changed. She's on Coumadin, so the crew places an intravenous port carefully, to avoid excessive bleeding. Her elevated blood pressure gives them an opportunity to use nitroglycerin to assist in offloading some of the heart workload, and they ask the husband to check her usual daily dose of diuretic medication. But these medications are going to take some time to provide relief, so the medics consider their options.

     The crew had recently trained on a new assist device that provides continuous positive airway pressure, or CPAP. The equipment had been added to their vehicle, and their protocols adapted to add its use for patients with this presentation. They retrieve the equipment, explain the procedure to the patient and her husband, and apply the tight-fitting mask to the patient's head.

     "We're using this to assist your breathing without having to put a tube into your airway or assist you with a ventilator," the lead medic tells her. "It's a little noisy and will be tight on your face, but it'll make it easier for you to breathe and relieve the stress on your heart and lungs."

     The crew is hopeful this will help the patient avoid complete exhaustion and respiratory failure. They will rely on their continued observation, the pulse oximeter and the cardiac monitor to provide feedback.

     The CPAP device is placed, and the pressure in the airway circuit set at 5 cm of water. Although they close the bag with the endotracheal tubes, they keep the bag-valve mask close by.

     As they watch the patient, they ask the husband for more history. He says his wife hosted a family celebration the day before, and may have worked a little too hard. She was up all night trying to breathe, finally sitting up in the chair. During the night, she struggled more. They'd discussed her condition, and she'd said if she got worse, she could not go on a ventilator again. She'd been hospitalized once for heart bypass and twice with congestive heart failure. She hated being on a ventilator, and never wanted to experience it again.

     The crew asks a few more key questions. Overnight she'd complained of no pain, fever or nausea. She wasn't coughing. When she got sweaty, the husband says, he knew it was time to call EMS. His wife usually gets up in the morning to urinate and weigh herself, but was too weak to do so this morning. She'd eaten nothing overnight. Her ankles were usually swollen, and she usually controlled the dose of her water pill based on her weight.

     The husband is obviously well-attuned to his wife and her care. He's also astute enough to note the crew's concern about her distress, and the fact they kept the bag-valve mask out.

     "Remember," he says, "we've both told you she doesn't want the tube in. If she quits breathing, we don't want her to be artificially ventilated."

     Fortunately, there is now improvement in the woman's breathing. She is struggling less, her diaphoresis is clearing, and her respiratory and heart rates are slowly decreasing. The lead medic asks the patient to open her eyes, and she does. When asked if she's having pain, she shakes her head no.

     It's time to move to the medic for transport. They keep her in an upright position. En route to the hospital, she can follow the crew's instructions and shake her head yes and no to questions. In the upright position her pulse oximetry reading surpasses 90%. A final set of vital signs allows the crew to report significant improvement to the husband.

Hospital Management
     The ED is prepared for the patient's arrival. The hospital and EMS system had prepared for using the CPAP by agreeing on the type of equipment and its application to patients. ED staff transfer the patient onto their cart and switch the apparatus over to their oxygen source. The EMS crew reports the patient is breathing much more easily, and her eyes are now open. She now even offers a spontaneous complaint, pointing to her full bladder. A Foley catheter is inserted and drains about 800 cc of urine.

     About an hour later, after further ED care, the patient can be removed from the CPAP device and placed on supplemental oxygen by cannula. She and her husband are still in the ED two hours later when the Attack One crew brings in another patient. The woman is now awake and talking with her husband, and they relate that she'd had about 2 liters of "extra fluid" that was diuresed. Doctors reported her heart had not suffered any obvious damage. The husband says she "maybe had a little too much salt on her food" at the celebration the day before. The cardiologist caring for her has already requested that a dietitian talk with her about "holiday foods" that may be dangerous to patients monitoring their sodium intake. He's admitting her for a short observation period, but suggests she might be released that evening.

Case Discussion
     Continuous positive airway pressure is an important new tool for patients with certain lung and heart problems. CPAP is a form of noninvasive mask ventilation that allows some patients to receive respiratory support without the need for endotracheal intubation. This prevents the complications of intubation and, as this case demonstrates, the need for ventilator support, which some patients don't want. There are obviously situations where endotracheal intubation and positive-pressure ventilation are needed and requested, but noninvasive (no intubation) ventilation support has a growing role in patients having acute exacerbations of heart and lung problems.

     This case demonstrates use of CPAP in a patient with congestive heart failure. In these patients, CPAP ventilation increases intrathoracic pressure and decreases venous return. Although it's an easy explanation for patients, it does not, in fact, "push fluid out of the lungs." Reducing venous return decreases the work of breathing, assists the patient with inspiration and reduces bronchospasm. Together, these physiologic effects result in better oxygenation of the heart, better heart function and improved perfusion to other organ systems. Research has verified better outcomes for CHF patients managed with CPAP.

     Ventilating a patient with CPAP is done with a tight-fitting mask and a set of valves and tubes driven by pressurized oxygen. The patient is usually started with a pressure of about 5 cm of water. The patient must be able to tolerate the mask. Some may require medication to be comfortable with the mask in place, but sedatives must be used carefully, or you risk complete respiratory failure. CPAP is not definitive treatment for congestive heart failure, so other treatment will be needed to improve heart function or reduce volume overload.

     Unsuccessful use of CPAP to improve the condition of CHF patients is often due to poorly fitted masks, but can also occur if a patient's condition has deteriorated too much before use of the device. In this case, endotracheal intubation and positive-pressure ventilation are needed.

     Use of CPAP must be guided by local protocol. Consider any purchases in coordination with the local emergency departments. Since it's beneficial for EMS providers to work with hospitals and other organizations to implement new technologies, some agencies have joint research and development efforts with EMS and hospital partners.

Jim Augustine, MD, FACEP, is the medical director for a number of fire services in the Atlanta area, including Atlanta Fire Rescue. He is a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton, OH. He is a member of EMS Magazine's editorial advisory board. Contact him at jaugustine@emp.com.