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Online Discussion: Tracking new emerging diseases and the next pandemic; Now tracking the Aussie Flu.

HOME REHYDRATION AND BREATHING ASSISTANCE

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skylight View Drop Down
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    Posted: July 19 2009 at 6:52pm
CAN A CPAP MACHINE BE USED AS HOME VENTILATOR?
HOW CAN I DO IV HYDRATION WHEN THE MATERIALS ARE BY DR. PRESRCIPTION ONLY?
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Mary008 View Drop Down
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Mary008 Quote  Post ReplyReply Direct Link To This Post Posted: August 11 2009 at 11:49pm

Respiratory Management of ARDS - is there a role for home CPAP?

<In general, once someone has ARDS, we are talking about ICU’s and ventilators. But I am a very obstinate person and refuse to believe that you are doomed if you can’t get help from your hospital so I will attempt another round of brainstorming here.

<Again the usual disclaimers about this not being medical advice and neither myself nor anyone connected with this site can be held liable for any adverse consequences, etc apply. This post is offered ONLY to address the situation where you have tried to find medical care for someone who needs hospitalization and failed, NOT as part of a pre-determined plan to stay home and not try to seek help.

<I wrote this with the intention that someone with minimal medical knowledge can understand enough at least to start exploring possibilities. On the other hand, I need to include a small amount of technical discussion to make it coherent and for the benefit of those with some background in healthcare.

<Even if you are not able to do this as an individual, it may be worth exploring this for community preparedness.>

It seems to me that there are a couple of places where timely action might make a difference to survival. What triggers ARDS is the massive cytokine reaction to the huge amount of virus replicating in the body. So the first critical point of intervention would be getting tamiflu in the system fast, which I covered in the this post. http://*****.com/index.php?n=Forum.HowToMakeTamifluWork

The second critical point of intervention would be very early respiratory support in an attempt to halt or reduce the lung damage that can set off a vicious cycle in ARDS.

A simplified description of ARDS would be an acute massive lung inflammation with congestion and exudates (fluids) in the part of the lungs that are critical for oxygen absorption, so that the person rapidly becomes hypoxic (lack of oxygen). At the same time, because the lungs are waterlogged (think of a wet dish-cloth or sponge), they become much less able to expand properly.

Respiratory support essentially provides two things, oxygen, and the ability to expand the lungs. Of these, the second can often be more critical than the first.

In a hospital setting, respiratory support usually takes the form of machine assisted breathing (ventilation). This is commonly done by putting in a tube (ET endotracheal tube) down the throat into the lungs. This requires a high degree of skill and care, normally in an ICU, and the patient generally has to be sedated. The ventilator not only delivers oxygen to the lungs but also does that at a pressure slightly higher than atmospheric throughout the respiratory cycle (CPAP - continuous positive airways pressure or PEEP positive end expiratory pressure), thus helping to expand the lungs properly. In addition, the ventilator may take over the mechanics of breathing completely (IPPV - invasive intermittent positive pressure ventilation).

There have not been many major breakthroughs in the treatment of ARDS, but one recent trend has been to move from ‘invasive’ ventilation IPPV to ‘noninvasive’ ventilation NPPV using masks (or nasal tubes) instead of ET tube. As long as you can set up an airtight circuit, masks can be a very effective way of providing CPAP and ventilation. In fact, during SARS, because of the high risks of infecting health care workers during intubation, the later cases were often treated solely with NPPV. Well managed NPPV _STARTED EARLY_ can have a comparable degree of success as IPPV. You can use the usual hospital ventilator for this but you can also use machines specially designed to deliver CPAP.

CPAP machines (and their newer cousins such as BiPAP, but I will use the term CPAP inclusively) are also used as treatment for a common condition called obstructive sleep apnea. It works by providing a little extra pressure which stimulates breathing and improves oxygenation. The difference is that oxygen is not routinely used for home treatment of sleep apnea.

IF you or someone in your family already use a CPAP machine for sleep apnea, I can imagine a scenario where an experienced user may be able to use that for himself or someone in the family as respiratory support for avian flu. You would need to do a bit of homework ahead of time to figure out what might be safe levels of pressure to use, depending on the machine. You also have to make sure the mask is fitted properly to stop air from leaking. (A very small amount of leakage will not render the whole process useless.) In addition, it would be prudent to put in viral filters at both ends of the breathing circuit, and either sterilize the whole circuit including the mask between users or use disposable ones.

Because it is a lot safer than IPPV, CPAP can be started a lot earlier, i.e. when the patient is just beginning to have breathing difficulties instead of waiting till they are cyanotic (turning blue) or moribund. It requires a far lower level of skill to set up and monitor. There is less risk of trauma or secondary infection. In addition, there are many advantages to having the patient retain consciousness – they can respond to any accidental disruption in the respiratory circuit, co-operate better in synchronizing with the machine, in clearing secretions, in giving feedback on comfort level, and in any posture changes (see below). Being able to communicate is also a big psychological boost to both patient and family. Once they get better, the mask can be removed for short intervals, eg for food. It is also a lot easier to wean someone off a CPAP machine than a ventilator giving IPPV.

The main danger would be using pressures that are too high and causing lung injury. This is less likely if you stay well within the pressures recommended for the machine by your provider and the patient retains consciousness and control. The other one would be the risk of infecting carers from expired air forced out by the pressure in the mask. This can be reduced as I said earlier with the use of filters but it would still be prudent to maintain a high level of respiratory protection for the carer within 1 m of the patient.

If you have oxygen and experience with using it, you can certainly add that to the circuit. If the patient is obviously having difficulties with breathing, it is better to start with a high O2 concentration to reverse hypoxia as quickly as possible. Adequate oxygenation helps cardiovascular and other organ functions on top of the obvious respiratory benefit, which can make a big difference in the outcome.

<I cannot get more specific than what I have written because there are too many variables in machines, masks, O2 supplies, user experience, etc.>

Some important do’s and don’ts:

1. Start at a low pressure and increase very gradually according to the patient’s comfort level. STOP if there is no improvement, chest pain, mask intolerance, rising patient discomfort or agitation.

2. Maintain only enough pressure to stabilize and retain any improvement i.e. there is little benefit and much hazard in increasing pressure if there is already improvement.

3. Do not use if patient is not fully conscious and co-operative.

4. Only use this for young previously healthy individuals with NO HISTORY OF CARDIAC OR RESPIRATORY PROBLEMS.

5. Initially, patients should generally not eat or drink except for clear fluids taken in small amounts. In addition to the risk of vomiting and choking, in the acute phase of ARDS, there is often too much fluid in the lungs so it is better to take less than more as long as there is some urine output.

6. Pay strict attention to infection control, use PPE and viral filters, etc.

7. GET HELP! This is intended as a stop-gap or fall-back measure, not a substitute for proper medical care if available. On the other hand, you should not hold back on using this while waiting for help as time is crucial to survival.

8. ARDS is a complex medical emergency often with multiple organ dysfunctions or even failure. Respiratory support is very important but on its own is likely to have limited effect on survival. On the other hand, early action that reduces lung damage and improves oxygenation to other organs is likely to improve the success of any subsequent medical interventions

One more thing you can use at home is prone positioning (lying on the front). This helps to improve the balance between blood flow and oxygenation in the lungs, as well as recruit healthier under-utilized parts of the lungs. You may need a few small pillows to support the upper chest and pelvis for comfort. It is useful to change postures frequently, still maintaining a more-or-less prone position for as long as the patient can tolerate it. This has been used by various centers with some success, particularly when started early (before significant lung damage) and for long periods (eg >20 out or 24 hours for however many days that the patient is having respiratory problems). Vigorous physiotherapy to mobilize stagnant fluids in the lungs can be done as frequently as tolerated.

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Mary008 View Drop Down
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Mary008 Quote  Post ReplyReply Direct Link To This Post Posted: August 11 2009 at 11:53pm
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Post Options Post Options   Thanks (0) Thanks(0)   Quote Wishbone Quote  Post ReplyReply Direct Link To This Post Posted: August 21 2009 at 5:17am
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Post Options Post Options   Thanks (0) Thanks(0)   Quote johnson33 Quote  Post ReplyReply Direct Link To This Post Posted: August 29 2012 at 1:54am
Originally posted by Mary008 Mary008 wrote:

Respiratory Management of ARDS - is there a role for home CPAP?

<In general, once someone has ARDS, we are talking about ICU’s and ventilators. But I am a very obstinate person and refuse to believe that you are doomed if you can’t get help from your hospital so I will attempt another round of brainstorming here. 

<Again the usual disclaimers about this not being medical advice and neither myself nor anyone connected with this site can be  held liable for any adverse consequences, etc apply. This post is offered ONLY cialis online to address the situation where you have tried to find medical care for someone who needs hospitalization and failed, NOT as part of a pre-determined plan to stay home and not try to seek help.

<I wrote this with the intention that someone with minimal medical knowledge can understand enough at least to start exploring possibilities. On the other hand, I need to include a small amount of technical discussion to make it coherent and for the benefit of those with some background in healthcare.


Thanks Mary008 for the detailed answer..
Dani
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