Special oxygen mask may save lives

Stephen Letso has asthma, so shortness of breath isn't that unusual. But on an early morning in February, when an inhaler wouldn't control his symptoms, he was afraid he would never catch his breath again.

Wheezing and coughing almost uncontrollably, the 72-year-old retiree managed to call a neighbor .

"My friend dialed 9-1-1 right away," Letso said recently as he sat in his North Las Vegas home. "I was just about out of it."

Within minutes of the emergency call, a MedicWest ambulance arrived. Almost immediately, paramedics realized a regular oxygen mask -- which delivers oxygen but requires effort by the patient to breathe it -- wouldn't solve Letso's distress.

Turning blue from oxygen deficiency, he simply didn't have the wherewithal to breathe on his own.

At that point in the past, Letso would have been intubated, a tube placed down his throat so the oxygen he desperately needed could be pushed into his airway on the drive to the hospital.

But the paramedics decided to use "continuous positive airway pressure," or CPAP, a less invasive treatment that is new to Southern Nevada and is part of a current University of Nevada School of Medicine study.

A special CPAP mask was put over Letso's face and continuous high-pressure air was delivered through his trachea and down through his lungs as he was taken to MountainView Hospital.

CPAP devices, studies by other ambulance services around the country have shown, are effective therapy for patients with compromised air sacs in the lungs where the exchange of oxygen and carbon dioxide takes place. Oxygen-rich gas is supplied at flow rates high enough to increase airway pressure. And then the patient exhales against a resistance called positive end expiratory. This combination helps reduce the work of breathing.

Soon after the mask was put on him, Letso's breathing improved.

"That may well have saved his life," said Larry Johnson, clinical manager for the MedicWest and American Medical Response ambulance companies that are associated with the study that has University Medical Center as the lead hospital.

KEEPING PATIENTS OFF VENTILATOR

How CPAP may have saved his life isn't measured at the scene -- intubation certainly would have gotten Letso breathing -- but rather by what happened to him later at the hospital.

Generally when someone is intubated by first responders, that individual must stay on a mechanical ventilator at the hospital, often ending up in intensive care.

And that, says Dr. Bryan Bledsoe, clinical director for emergency medicine at the state's school of medicine in Las Vegas as well as the author of several books on the subject, greatly increases health risks for a patient.

"If we can keep patients off the ventilator, their outcomes will be a lot better," said Bledsoe, a UMC emergency physician and medical director for MedicWest and American Medical Response. "Their risk for dangerous hospital-acquired infections and pneumonia is much higher. And there is also the risk for elderly patients that they become ventilator dependent, never become weaned from the ventilator, and they die that way."

MountainView Hospital doctors found out pneumonia had caused Letso's severe breathing problems .

"Intubation probably would have exacerbated his condition," Johnson said, pointing out that Letso isn't young and strong and would probably have had a difficult time building up the strength to ever get off the ventilator.

On a ventilator, Bledsoe noted, patients are in particularly precarious position, sedated and having to be chemically paralyzed so they can't move. They require constant nursing care. Invasive catheters and other tubes, which can carry infection, are commonplace.

Emergency medical service directors have reported in the Journal of Emergency Medical Services that as many as 50 percent of intubated patients admitted to hospitals ended up being treated for respiratory infections, particularly ventilator-associated pneumonia, and that 54 percent of these patients eventually died from their infections.

According to the Centers for Disease Control, more than 99,000 people in the United States die each year from hospital-acquired infections. And for every person who dies from an infection, another 20 suffer through infections that sometimes leave them in the hospital for months or with a permanent disability.

In fact, about 5 percent of people admitted into the hospital each year (or about 2 million people) become infected with a hospital-acquired infection, costing the health care system between $30 billion and $40 billion.

BENEFICIAL RESULTS

So far the study carried out in Las Vegas has found that of the 106 patients on which the CPAP mask was tried since February, 70 percent benefited, with medical officials reporting that the patients did not have to go on a mechanical ventilator.

"CPAP was highly effective in the treatment of dyspnea (difficult or labored breathing) associated with asthma, chronic obstructive pulmonary disease, congestive heart failure, and pneumonia," states a preliminary report written by Bledsoe and Johnson to the Southern Nevada Health District.

Those conditions generally see a fluid buildup in the lungs. CPAP's continuous positive pressure of air, pushing the fluid back into the soft tissue, allows gas exchange to flow better and simplifies a patient's ability to take a breath.

"Once I had that mask on, I was actually able to take a deep breath," Letso recalled. "It really helped me."

If the preliminary results of the Las Vegas study stay about the same for about 300 patients, it's expected that the health district will require the CPAP on all emergency medical service vehicles in Southern Nevada.

The cost effectiveness of CPAP, which is also used by some people with sleep apnea, is also appealing.

The Journal of Emergency Medical Services published a study that showed that 120 CPAP patients had an average hospital stay of about five days, compared with 10 days for the intubated patient , five days of which were spent in intensive care at a cost of three to four times that of the general ward. That study reported that the use of CPAP resulted in a hospital cost saving of nearly $500,000.

Letso, though he had severe pneumonia complicated by asthma, spent less than six days in the hospital. He had multiple antibiotic and breathing treatments, but he never had to be put on a ventilator in intensive care.

"These CPAP masks only cost $40," Johnson said. "From what I've seen, it's got to be one the best investments emergency medical services can ever make."

Contact reporter Paul Harasim at pharasim@reviewjournal.com or 702-387-2908.

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Comments

Note: Comments made by reporters and editors of the Las Vegas Review-Journal are presented with a yellow background.

1. Ken.O May 31, 2011 | 7:34 a.m. Report Abuse

   @Informedblogger - Did some research last night, and made a few phone calls. Number one - the fire departments were in the test phase when they ran all those commercials slamming private EMS for not having the hypothermia systems...according to you, it wouldn't have been approved by SNHD when they ran those ads, but they used it to their advantage. Number two - only the City of Las Vegas Fire Department uses those mechanical CPR machines...not every FD, only LVFD! Number three - the studies that show the efficacy of those machines point to the thumper type, and not the "geezer squezzer" version the LVFD uses. Fourth - the induced hypothermia can ONLY be used on a VERY small number of patients in Clark County! It is a great thing if it saves a life, but it not used that often. I got this information from a National Faculty Member of the American Heart Association, so unless you have someone who is willing to dispute this, I think it's clear what the truth is! The local FF unions use the numbers that suit them, and their personal agendas. BTW, since you seem to be much better informed than me, what ever happened with the investigation into that Fire Fighter Union President Fletcher for poss. DUI/Hit and run/leaving the scene of an accident deal? I notice it just disappeared...@sweetcndy...no I didn't, just another line of union BS to take the heat off you guys! :) Have a great week!!!

2. ruthven78 May 30, 2011 | 11:19 p.m. Report Abuse

   @ken.o - in most communities the fire department and ambulance service are two completely seperate entities. In "most" communities the fire department does not control or manage the ambulance company.
   
   The fire department already trailed the devices and there are a lot of districts that already use CPAP. It is in the "catching on" phase....the phase right before standard operating protocol.

3. LV.Medic May 30, 2011 | 11:16 p.m. Report Abuse

   Informed blogger: yes the fire dept are using CPR boards. The last 4 cardiac arrests I ran with the fire dept, the boards did not work because of dead batteries or other mechanical difficulties.
   As far as theraputic hypothermia, I believe it was a few key physicians that insisted LV begin using the treatment.
   As far as tax dollars are concerned, how are your thoughts on paying taxes that subsidizes the fire dept and then being billed by them when they transport you?
   Perhaps you should get your facts straight before you go throwing out your ill informed criticism.
   
   I wish everyone will get off of the FD vs. Private soap box. Even though the media continuously paints some type of war between the two, you should see them (FD & private) in action to get the job done to save a life. Its pretty amazing how well they work together.

4. Jack.Webb May 30, 2011 | 8:34 p.m. Report Abuse

   "liberalslie wrote on May 30, 2011 11:02 AM: You also need an O2 supply. Entire units are available on Ebay or other online sites. The mask alone won't do much good. Pick up a portable unit and you're good to go."
   
   Nonsense, doctor. Just hook the mask up to the exhaust pipe of your lawnmower and you're good to go!

5. Ken.O May 30, 2011 | 5:05 p.m. Report Abuse

   Dear informedblooger-My point exactly! If this is a trail, why is the fire department NOT involved? Wouldn't and shouldn't they be most concerned?
   
   As far as my tax dollars going to another state I was not aware tax payers subsidized either AMR or Medicwest, it is my understanding that we only support the fire department for EMS...The private companies are paid by insurance and Medicare/medicaid just like fire when they transport...
   
   If you are aware of something otherwise, please post it, I would be very interested to see it, but please post a contract or line item number, not just an opinion...
   
   Have a great weekend and don't forget the real heros of this country, our veterans!!! Semper Fi!

6. Dan May 30, 2011 | 4:53 p.m. Report Abuse

   Umm, uninformedblogger, the CPR machines, otherwis known as thumper, are not that great and most departments that have used them don't use them anymore.
   Nice try though.

7. Sweetcndy May 30, 2011 | 3:54 p.m. Report Abuse

   Hey Ken.O, You got TOLD! Haha! Your a tool!

8. Wondering citizen May 30, 2011 | 3:31 p.m. Report Abuse

   Yes let's state the facts. This is not approved by the health district because it is in it's trial stages. That is because the FD did not do a trial run. This is the first time these have been here and are actually working very well. Now the CPR machines were not done in a trial bases and where the thought of them is great they fail 86% of the time showing a loss in CPR. this is why one 1 out of 6. Agencies in southern nevada is still using it.

9. dan.charyk May 30, 2011 | 12:01 p.m. Report Abuse

   There is an error in your report,the CPAP mask may cost$40.but the CPAC machine that delivers the air costs $1600. (in canada) They can be adjusted to deliver air pressure on a scale of 1-10 depending on the amount of air required to keep the air passage open. In canada the gov. pays 75% of the cost and you can get a new machine every 5 years. I have had a CPAP machine for sleep apnea for 20 years and they have advanced greatly over time.

10. informedblogger May 30, 2011 | 11:06 a.m. Report Abuse

    To clarify: the fire departments have already done their trial runs on this device over a year ago.

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