Pulmonology Book

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Continuous Positive Airways Pressure

Aka: Continuous Positive Airways Pressure, CPAP
  1. Indications
    1. Sleep Apnea
    2. Loud continuous snoring
    3. Alternative to intubation in severe respiratory illness (or Bipap)
      1. Adult Respiratory Distress Syndrome (ARDS)
      2. Refractory Hypoxemia
  2. Contraindications
    1. Central Sleep Apnea
  3. Physiology
    1. Pressure above atmospheric maintained at airway opening
      1. Maintained throughout respiratory cycle
      2. Acts as airway splint to prevent collapse
      3. Used during spontaneous breathing
    2. Same end-expiratory pressure as with PEEP
    3. Lower Inspiratory pressure excursion than with PEEP
      1. CPAP requires less pressure to open
      2. PEEP requires a greater work of breathing
  4. Dosing
    1. Usual dose: 6 to 12 cm H2O (Range: 3 to 20 cm H2O)
    2. Higher pressure (within range above) indications
      1. Heavier weight
      2. Short-thick necks
      3. More severe Sleep Apnea
  5. Equipment: Sleep Apnea Management
    1. Nasal pillows or full face mask
    2. Small quiet air compressor
  6. Technique
    1. Requires specially-designed, tightly fitting masks
    2. Mask should have pressure-limiting valves
  7. Adverse Effects: Relates to decreased mask tolerance
    1. Nasal dryness or congestion
    2. Mask air leakage
    3. Claustrophobia
    4. Skin irritation or abrasions
    5. Conjunctivitis
  8. Adverse Effects: Methods to improve compliance in Sleep Apnea
    1. Optimize mask fit for size and shape of face
    2. Utilize mask option patient finds most comfortable
      1. Full face mask
        1. Appears similar to Simple Oxygen Mask
      2. Nasal pillows
        1. Soft adapters fit within both nares
      3. Consider alternating methods
    3. Patient should follow-up to make CPAP adjustments
    4. Treat underlying nasal symptoms (e.g. nasal steroid)
    5. Humidify or cool inspired air
    6. Consider otolaryngology consult if CPAP not tolerated
  9. Efficacy: Sleep Apnea
    1. First line, very effective Therapy
    2. Reduces coronary ischemia in those predisposed
      1. Peled (1999) J Am Coll Cardiol 34:1744-9
    3. Reduces Blood Pressure in hypertensives
      1. Becker (2003) Circulation 107:68-73
      2. Pepperell (2002) Lancet 359:204-10
  10. Precautions
    1. CPAP will worsen Central Sleep Apnea
      1. Do not use CPAP empirically without Sleep Study
      2. Decreases respiratory drive
  11. Management: Follow-up of CPAP monitoring in Sleep Apnea
    1. Snoring despite CPAP?
      1. Is CPAP pressure is too low?
      2. Is there a leak at the interface?
      3. Is the patient sleeping with mouth open?
      4. Does the patient use excessive Alcohol?
    2. Weight change since CPAP was started?
      1. Reassess CPAP if weight gain exceeds 10%
      2. Consider overnight oximetry
        1. Calculate desaturation index = (4% desats)/hours
        2. Desaturation index <5 is normal
    3. When was CPAP last checked?
      1. Mask should be changed every 6 months
      2. Check blower every 12 months
    4. Is the patient still symptomatic?
      1. Is patient compliant with CPAP?
      2. Is the patient allowing enough time for sleep?
      3. Are there problems with Sleep Hygiene?
      4. Are other conditions keeping patient awake?
        1. See Insomnia
        2. Consider restless legs
      5. Other conditions making them sleepy (e.g. Narcolepsy)
    5. Problems with CPAP?
      1. Intollerant of air pressure
        1. Activate CPAP ramp up or increase ramp time
        2. Add a CPAP humidifier
        3. Consider a full CPAP face mask
        4. Consider specific devices (Auto-adjust, C-flex)
        5. Consider lowering CPAP pressure by 1-2 cm H2O
        6. Sleep center to calibrate device pressure
      2. Vasomotor Rhinitis or congestion
        1. CPAP heated humidifier
        2. Consider nasal steroid for congestion
        3. Consider intranasal Ipratropium for Rhinitis
      3. Mask or pillow leaks
        1. Adjust the straps, pads
        2. Check that the device is not upside down
        3. Wash face at bedtime and wash device daily
        4. Sleep center to switch mask types
      4. Claustrophobia
        1. Wear mask when reading or watching television
        2. Sleep center to resize mask
      5. Patient pulls off headgear while asleep
        1. Add chin strap or adjust for better fit
        2. Use a disconnect alarm
      6. Difficulty initiating sleep
        1. See Sleep Hygiene
        2. Wear mask when reading or watching television
        3. Assess for other causes (e.g. restless legs)
  12. References
    1. Marino (1991) ICU Book, Lea & Febiger, p. 379-80
    2. Bower (2000) Otolaryngol Clin North Am 33(1):49-75
    3. Flemons (2002) N Engl J Med 347:498-504
    4. Gozal (1998) Pediatrics 102:616-20
    5. Owens (1998) Pediatrics 102:1178-84
    6. Piccinillo (2000) JAMA 284:1492-4
    7. Sliverberg (2002) Am Fam Physician 65(2):229-236
    8. Victor (1999) Am Fam Physician 60(8):2279-86
    9. Victor (2004) Am Fam Physician 561-74

Continuous Positive Airway Pressure (C0199451)

Definition (MSH) A technique of respiratory therapy, in either spontaneously breathing or mechanically ventilated patients, in which airway pressure is maintained above atmospheric pressure throughout the respiratory cycle by pressurization of the ventilatory circuit. (On-Line Medical Dictionary [Internet]. Newcastle upon Tyne(UK): The University Dept. of Medical Oncology: The CancerWEB Project; c1997-2003 [cited 2003 Apr 17]. Available from: http://cancerweb.ncl.ac.uk/omd/)
Concepts Therapeutic or Preventive Procedure (T061)
MSH D045422
ICD10 92038-00
SnomedCT 229307008, 47545007, 229309006
English Continuous positive airway pressure [CPAP], CPAP, CPAP - Cont pos air pres ther, Cont pos airways pres therapy, Cont positive airways pressure, Continuous positive airways pressure, Continuous Positive Airway Pressure, continuous positive airway pressure ventilation, continuous positive airway pressure ventilation (treatment), Continuous positive airways pressure (observable entity), CPAP (continuous positive airway pressure ventilation), Pressure.continuous positive airway, cpap ventilation, continuous positive airway pressure (CPAP), cpap treatment, Continuous positive airway pressure, CPAP Ventilation, Ventilation, CPAP, Continuous positive airway pressure ventilation treatment, CPAP treatment, CPAP - Continuous positive airways pressure, Continuous CPAP, Continuous positive airways pressure therapy, CPAP - Continuous positive airways pressure therapy, Continuous CPAP (regime/therapy), Continuous positive airway pressure ventilation treatment (regime/therapy), Continuous CPAP (procedure), Continuous positive airway pressure ventilation treatment (procedure), CPAP (continuous positive airway pressure), continuous positive airway pressure
Italian Pressione continua positiva delle vie aeree, Pressione positiva continua delle vie aeree, Ventilazione CPAP, Pressione positiva continua delle vie respiratorie
French CPAP, PPC (Pression Positive Continue), Ventilation PPC, Ventilation CPAP, VPPC, Ventilation en pression positive continue, Pression positive continue des voies aériennes supérieures, Pression des voies aériennes positive continue
German CPAP, kontinuierlich positiver Druck der Atemwege, Continuous Positive Airway Pressure, CPAP-Beatmung, Kontinuierlicher positiver Atemwegsdruck
Japanese 持続的気道陽圧, ＣＰＡＰ, ｼﾞｿﾞｸﾃｷｷﾄﾞｳﾖｳｱﾂ, CPAP, 経鼻的持続気道陽圧呼吸, 持続陽圧気道圧, 経鼻持続気道陽圧, 持続的気道陽圧法, 持続気道陽圧, 気道圧解除換気法
Swedish Kontinuerligt positivt luftvägstryck
Czech trvalý přetlak v dýchacích cestách, CPAP, Kontinuální pozitivní tlak v dýchacích cestách
Spanish Continuous positive airways pressure, CPAP, presión positiva continua de la vía aérea (régimen/tratamiento), presión positiva continua de la vía aérea, tratamiento de CPAP, tratamiento de ventilación con presión positiva continua en la vía aérea (procedimiento), tratamiento de ventilación con presión positiva continua en la vía aérea (régimen/tratamiento), tratamiento de ventilación con presión positiva continua en la vía aérea, ventilación mecánica controlada, Presión de vía respiratoria positiva continua, Presión de las Vías Aéreas Positiva Contínua, Presion de las Vias Aereas Positiva Continua
Finnish CPAP
Russian DYKHATEL'NYE PUTI, POLOZHITEL'NOE DAVLENIE POSTOIANNOE, ДЫХАТЕЛЬНЫЕ ПУТИ, ПОЛОЖИТЕЛЬНОЕ ДАВЛЕНИЕ ПОСТОЯННОЕ
Polish Pomoc oddechowa typu CPAP, Ciągłe dodatnie ciśnienie w drogach oddechowych, Terapia oddechowa ciągłym ciśnieniem dodatnim, Stałe dodatnie ciśnienie w drogach oddechowych, Ciśnienie stałe dodatnie w drogach oddechowych, CPAP
Hungarian Folyamatos pozitív légút nyomás, CPAP
Portuguese Pressão positiva contínua nas vias respiratórias, Pressão Positiva Contínua nas Vias Aéreas, Pressão Positiva Contínua nas Vias Respiratórias, Ventilação com Liberação de Pressão das Vias Respiratórias, VLPVA
Dutch continue positieve luchtwegdruk, APRV, Continuous Positive Airway Pressure, CPAP
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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