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Adults/Adolescents/Pediatric ages with moderate to severe respiratory distress (dyspnea) that is not related to trauma or injury with any of the following:

- Pulse oximetry less than 90%, not improving with routine therapy

- Respiratory rate greater than 26 per minute (50 Pediatric) and pulse oximetry less than 95% and not improving

- Respiratory distress with accessory muscle use or retractions

- Wheezes, rales, rhonchi, not improving with routine therapy

- Respiratory distress with fatigue and decreased effort of breathing



- CHF, Pulmonary Edema, Asthma, COPD, CO Poisoning, Cyanide Poisoning, Non-Fatal Drowning, and Smoke Inhalation

- All other indications BHO



- Altered level of consciousness, inability to protect airway from aspiration

- Inability to remain in a sitting position

- Respiratory arrest or failure with agonal respirations (use advanced airway measures)

- Cardiac arrest (use advanced airway measures)

- Blood pressure less than 90 systolic (80 Pediatric) or signs of poor perfusion

- Upper gastrointestinal hemorrhage or history of stomach surgery in past month (including lap-band)

- Nausea or vomiting

- Nasal or oral bleeding

- Suspected pneumothorax

- Penetrating chest trauma

- Facial trauma or abnormality



1.  Provide supplemental oxygen for respiratory


2.  If wheezing, provide albuterol.

3.  Allow patient to assume position of comfort, which

is often a sitting or upright position.

4.  Explain procedure to patient.

5.  Document lung sounds before and after initiation of CPAP and every 5 minutes.

6.  Monitor pulse oximetry and document oxygen saturation.

7.  Assemble CPAP device and attach to oxygen source.

8.  Adjust starting CPAP pressure at 5 cm H2O (2-3 cm H2O for pediatric age group).

9.  If albuterol appropriate, may administer with CPAP in-line nebulizer.

10.  Attach CPAP mask to patient; ensure good mask seal and place ETCO2 monitor.

11.  Gradually increase CPAP pressure from 5 cm H2O to 7.5 to 10 cm H2O as tolerated (3-5 min. intervals) and titrated to patient effect (for pediatric age group, gradually increase CPAP pressure to 5 cm H2O maximum).

12.  Continuously observe patient.

***If using “Christmas Tree” connection in ambulance, utilize the 30% regulator only***



- Document time of CPAP placement; pressure being maintained and initial vital signs, pulse oximetry, and LOC. 

- If CPAP removed, document time and reason.

- Document full set of vital signs, lung sounds, pulse oximetry, level of consciousness and respiratory effort every 5 minutes.



CPAP therapy is most effective if maintained and continuous. CPAP should not be removed unless the patient cannot tolerate the mask and device, or there is deterioration requiring advanced airway management.

- Remove CPAP if nausea or vomiting occurs

- Remove CPAP if nasal or oral bleeding occurs

- Remove CPAP if blood pressure drops below 90 systolic

- Remove CPAP if patient unable to tolerate procedure

- Remove CPAP and provide advanced airway if: respiratory arrest, respiratory failure, agonal reps or hypoventilation



- Monitor patient for gastric distention, which may lead to vomiting.

- CPAP is appropriate therapy for a patient with a Do Not Resuscitate (DNR) Order who is in respiratory distress or failure.

- Advise receiving hospital as soon as possible of CPAP placement so that they can prepare for patient arrival and continued management.

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