Chelsea Kadish, MD & Kyle Goodknight, EMT-P, RT: Pediatric CPAP in EMS (3/14/25)

All right, everybody, we are live. It is March 14, Friday. Very excited for the end of the week because every week we have really incredible speakers. Tanner, Smita and I and Dr. Pepe are always grateful to have wonderful folks in the world of EMS and the folks who are coming on today. I actually met Kyle Goodnight up in Delaware County, Ohio, where they invited me to give a talk. And he sat next to me and he told me this very compelling story, a very personal story. And listen, I've been in pediatric ER for many, many years, and to hear this story happen in EMS and to see the fact that he's kind of planted a flag and said, I'm going to make this happen around the country, that's really the reason why I invited him. And he said, hey, you got to have Dr. Kadish come on with us. She's at him in Columbus, Ohio, working with Dr. Rob Lowe, who we all know and love from Columbus ems. So without any further ado, we're talking about pediatric CPAP in ems. Why not, right? So, Kyle and Chelsea, welcome if you want to go ahead and make some further introductions and then take it away. Thank you so much for joining the Florida EMS webinar.

Hi, everyone. Thanks for joining us today and thanks so much for having us here at this meeting. I'm Dr. Chelsea Kadish. I'm a pediatric emergency medicine doctor at Nationwide Children's in Columbus, Ohio, and I'm an assistant medical director here at Columbus Division of Fire. I also help locally with a lot of the other agencies in town with pediatric medical direction. And then we also have Kyle Goodnight. And Kyle is a paramedic at Delaware county ems and he's also trained as a respiratory therapist. So today we're going to talk to you a little bit about implementing pediatric CPAP at your agency. All right, so we have no financial disclosures, and today we wanted to review indications for CPAP in children and then discuss a little bit about how to put a child on cpap and also discuss some of the logistics of starting CPAP at your agency, including what equipment you'll need, what sort of protocol changes you might need to implement, and some skills training.

Hi, everybody. Thanks, Dr. Kish. Appreciate it. Yeah, so my name is Kyle Goodnight. I'm paramedic with Delaware county ems. Was and also restorate therapist. Been a restorate therapist since 97. So I've been a therapist almost 30 years and 20 of that have been a paramedic as well, working sometimes dual in both of those areas. So my story is very personal like Dr. Hantevy said, my. My daughter was six years old. Her brother had croup four or five days earlier, got taken to the ER, got treated and released, and then she went down with it a few days later and then woke up in the morning. You know, she had been. We'd walk, I shouldn't say the morning. It was about noon that I finally woke her up and she was pale and being a respiratory therapist and actually in medical sales at the time, actually had a pulse oximeter at home and I put her on a pulse oximeter and she was 89%. So I was like, oh, gosh, you know, let's get her in the car, let's take her down to close to home. You know, being a paramedic and, you know, if you've ever had anything happen to your own family, you just don't have that same intensity. Get her to the urgent care. And they called the squad and they rushed her down to Children's, Columbus Children's Nationwide Children's where Dr. Katish works. Now, she wasn't there back then, but. But yeah. So we're getting ready to. On our second racing MC epinephrine.

And her pressure was 40 over nothing. And he had the whole. The doc had the whole team in there getting ready to innovate her and being a therapist and seeing the, the benefits of CPAP and knowing that pediatrics have CPAP at the hospital settings, I asked the lead doctor, hey, do we have, do you have cpap? Can we try CPAP on her? We're going to know in like three or four minutes if it's going to help support her, her breathing. And he's like, man, that's a really good idea. Yeah, let's get that started. By the way, what do you do? And I said, well, I'm a respiratory therapist and a paramedic and my wife, who was in scrubs and is a pediatric nurse, so we have a very strong medical background. And unfortunately, we didn't see the signs and symptoms of her happening so fast. But we put her on the CPAP and this is her in the ICU. She spent about 15, 16 hours on BiPAP and this and it turned her around. And they did end up having to start a femoral line to get to do some norepinephrine to keep her pressure up. But breathing wise, she was stabilized with BiPAP. Well, fast forward a few hours. And one of my best friends who's also a paramedic locally in our hometown, Westerville, Ohio, we're Standing over her, looking at her, literally in this position. And he's like, kyle, why aren't we doing this in EMS? I said, well, most protocols say 12 years old, and she's 6. And he's like, but it doesn't matter. Look at. It's working. You know, why not. Why not do this? I'm like, well, we also don't have these masks in the field, and we don't have anything about it. And that was the day that Rob Glaze, firefighter for West Roll or West Rho Fire, kind of took as a champion with my. With my assistance of contacting not only Nationwide Children's and the physicians there, his medical director, the late Dr. Orth, Dr. Bubbles from nationwide Children's. She was another integral part of it, and then got a hold of the different companies to start talking about the different things that they need. So that. That was our story. Camden is now 20 years old and actually in the Dominican Republic right now. So. So it turned her around and took about six years to get it imp. But then we actually got it implemented, and she was invited into the Westerville Chamber of Commerce to. To talk about it. And because they had multiple success cases in pediatric respiratory, you know, help, and they brought her up on the stage and. And did a big thing, and it was. It was really cool for her to. To experience that. So that's my story and why we championed it to get it going. And at that point, I'll hand it back to Dr. Kadish.

Okay, so I just want to talk a little bit about the background for CPAP and why we use so much in kids. Respiratory complaints account for about a third of visits in children, and it accounts for a lot of the hospitalizations and deaths as well. And most children who go into cardiac arrest are going to go in because of a respiratory failure rather than a cardiac cause. That being said, respiratory is important in children.

Next slide. So signs of respiratory distress. I'm sure you all are sort of familiar with these, but I wanted to point them out just because these are some of the things that I look for when I think about a child who might need cpap. So tachypnea, retractions, nasal flaring, grunting if they're extremely tachycardic. And then in those little babies, they may present with apnea. And then once it gets more extreme to the point where you're really hypoxic, you might see a child becoming more restless or agitated or combative. And then somnolence or lethargy can also be Seen especially as the CO2 starts to rise. And another thing to keep in mind is tachypnea varies with age. I think we all are kind of aware of that. But just being comfortable with those sort of thresholds for when a child is tachypneic based on their age is important as well when you're thinking about cpap. This kid here just wanted to show you. This is a little boy with asthma who's had some retractions and some belly breathing. This might be a kid that I would consider starting CPAP on if they were presenting in the field.

But this one I wanted to share is this little four month old girl. She has bronchiolitis.

And you can hear her little grunting noise there. And her retractions, you can see on her belly, she's got some nasal flaring as well. So another kid that I would not hesitate to use CPAP on even in the pre hospital setting. And then this little kid here has some spider. He's pretty typically has the retraction.

For y'.

All.

So all three of these kids I think would be good candidates for CPAP in the field. So again, indications are going to be similar to an adult especially. I find it really helpful in kids who have asthma.

Those with bronchiolitis that we see in the younger age groups, pneumonia, pulmonary edema, it might be helpful in croup as well. And we have seen some good cases as well in kids who have submersion injury, which is what we call drowning the these days.

And then as long as the mask fits, I don't really have any problem with using it at any age child. I know there's some restrictions on some of the protocols pre hospital, but here at Columbus Fire we use it in any age child as long as the mask fits. Contraindications are going to be similar as an adult. So you don't want to put it on anyone who is altered, anyone who's not breathing adequately. If there's a need for airway protection, like in the case of anaphylaxis or an airway burn, that child should probably just be intubated. And then anyone who has facial trauma or any other reason that you can't get a good seal on the face, you don't want to put CPAP on. And then again consider pneumothorax.

And if you can't get the mask to seal properly. So Kyle's going to talk to you a little bit more about the logistics.

Yeah. So like I said, when, when this first got started, there had to be some creativity with it. You know, we have adult pediatric or we have adult CPAP generators in the field. And how does that transfer over to the. The pediatric patient? You know, in the hospital they have machines. They have a BiPAP machine by Phillips and it's got all these whistles and bells and all the. All everything. So when it comes to the. The main thing about the logistics and implementing this, what we've found locally is the mindset is really what we. It's a little bit different than adults. You know, Dr. Kadish mentioned earlier that, you know, most adults are doing, you know, pulmonary edema for cpap. That's not really something we see too often in kids. But we do see all those videos earlier that we have retractions. And I really want to make sure that we pound that home that retractions mean that that kid is in respiratory distress. And then if they're grunting, that's even worse. Because grunting is the pediatric version of pursed lip breathing. We all know what we do when we purse lip breathe is we're trying to generate pee. So a grun child is begging for peep. So that's the child that you really. That. That work of breathing is really what we have to change in our brain when it comes to. When we put this on a pediatric patient, along with oxygen saturation. If we're less than 92, I believe it's. Well, we talk about that in a couple minutes. But choosing the best equipment we do have. The generators are disposable now. Some of them are the old, you know, yellow boxes. I'll show you a picture of that in a few minutes. And all the different generators that are out there are not. Or some of them, not all of them. Um, protocol change is important. And then training, of course. And the training, like I said, really have to hit home when to implement this on a pediatric patient. There's so many people right now even bringing this up locally, they're like, well, that's really aggressive, Kyle. To do pediatric, to do CPAP on a pede. And I said, well, no, it's not. It's pretty. It's pretty uninva. It's in non. Invasive. So it's not aggressive. It's an aggressive idea because we've never done it before, but we've never had the choice to support a child like this and now we do. So it's actually very non invasive and very helpful. And the way that the mass fit is very. Is very tolerable by that child for the most Part, So I'll let Dr. Kadish talk about the protocol situation.

So this is kind of what one of our local protocols looks like. And here we just. We're just showing a pediatric respiratory distress protocol. And then once they do sort of their initial evaluation, then I kind of pulled this out and just to show it in larger print, that this is the point where if you're a hypoxic or working a breed that you would consider putting CPAP on, and there was some sort of local hesitancy about what age are we allowing this in? And we actually ended up removing from the protocol any age restrictions here. So we're allowing it on any age child as long as the mask fits.

And as long as there's no contraindications. The other question I do get a lot in regards to the protocol is whether or not we should be sedating children to put CPAP on, whether we should be giving them a little bit of Versed or ketamine. And in my opinion, I don't feel like we should sedate children who need CPAP just because I don't want to depress their respiratory drive any further. And I think that the ones who truly need CPAP generally tolerate the mask well, and they feel better after the mask is on their face. It might take a minute or so to let them adjust to it, but once they have that minute to sort of relax and let that pressure into their lungs, they feel better. And sometimes they even fall asleep as soon as the mask is on.

Okay. You know, when it comes to using it with kids, we do want to start at that lower level, that 5 millimeters of water. We can titrate it up to 10. We don't want to go higher than 10 on PEDs, but I always tell everybody to start at 5. That's also a really good place to start at when you're nebulizing. Along with cpap, we want to have that lower level to stent the airways open with the pressure and the peep, but then also get that meds deeper. As you can see in this one picture, this is how the full face mask fits on a child. And then there's adapters down here we'll talk about. And then there's the generator at the bottom here, Right where hopefully you can see my mouse and then your oxygen source. So this is basically the setup. We also have it on a couple of different size children here. With that being said, I do want to kind of just go over real quick the three different disposables that are most prevalent in our area. Of course, everybody's area is different and I know that there's other disposables out there along with one of the standalone that's been pretty well known throughout the years. So remember that all of these. We're really kind of focusing on the generator itself which is on this one. It's the orange. Don't. Don't focus on this normal adult mask. I couldn't find any pictures with just the generator only these are the pictures directly from the different sites that show it with an adult mask on it. So ignore the adult mask. We'll talk about mask in a couple of seconds. So this one is also by Palmodyne and it's the O2 Max. You know, it has a different way of generating a little bit more FIO2 than some of the others, but you have to switch parts and pieces out. It's still very. It's one. It was the one that they first started with. The next One is the O2 is the Go Pap by Palmodyne again. And this one is the one that we use here locally. I'm not sure which one Columbus uses, if it looks like this one or the orange one. But this one also has the automatic nebulizer in the bottom that you can put in and generate off another oxygen source and a very easy way to turn it. This one's also not as loud, the O2. The O2 Max is a very loud because it's using, as you can see, the green at the top. It's using 50 psi source to get the flow where this is using 10 liters a minute. So it's a lot less. It's a lot less loud for that child. Remember, ignore the mask for now. One of the other ones that's newer on the market is the Flomax 2 by Mercury Medical. This one also has a feature where they're calling it bipap where there's a switch between CPAP and bipap to give inspiratory pressure and expiratory peep. And. But it is all about the fittings and how the fittings from the generator fit into the mask. And we'll get to that in a couple of slides as well. The one that is a. Is a. A capital device. It's that yellow box. This is one of the early ones that I saw in the in EMS setting. It all still depends on this, the mass connection here. The CPAP on this one is generated and the flow is generated in the yellow box. And then this is where the mask would fit in this. I, we tried this out at one of, one of our lectures a couple years ago and everything fit just fine with all the same parts and pieces that you'll see here in a minute.

So the mask is, is why this works so well because it is a mask that fits above the eyes and below the mouth. So it fits as a total instead of here. So it's a lot more tolerable. And it kind of looks like an, it kind of feels and fits like an scba. This is one that is. This one's what, what we call the adult small because adults also can tolerate the, the full face mask as well. Palmodyne and Philips are your two main mask manufacturers. There may be a couple others out there, but PA is the ones that we use and we get those through boundtree. I think Boundary is pretty national, but also Philips is another one that can work as well. It just may need different parts and pieces to make things fit. And when I mentioned that the parts and pieces, as you can see on this previous one right here, this is a little bit bigger orifice than the next mask. When in here is where it connects to the generator here on this mask. This is also a Palmodyne and you know, Phillips has one very similar to this. But when it. And then this is the extra extra small. So there's extra extra small, extra small and then adult small are the three that we use. And the key is once again fitting it around the face in this dotted manner. Right here there is a size, there is a size meter that comes with each one that you can. Right here it's just a little card so it, it fits on the face like this to see which one it fits. And that's what. And that's how you determine if it's not one of these two. Then you bump up to the adult small. With that being said, we do need adapters to make it fit. You kind of saw on that other one it was kind of distance. I've got a better picture. But this is a 35 millimeter adapter. And 15 to to 35 and then a 22 to 22 and then the, the, the green one if you're using the Go Pap out there. And then, and as for adults, everybody knows what that green thing is. That's oxygen source to run your nebulizer separately. So those are the parts and pieces that you need. This is everything put together. You can see here in the middle that these, these just fall in line and, and connect. There's no way to connect those any differently than. Than what they put together. There's no, no backwards way that they can go. And I actually have a couple right here. I'll just take, you know, I have one of the masks right here, and along with.

I also have a small baby mannequin. So you can tell that this baby is not that. I mean, it's a very small child. And when we go to put the, the sizer on, you know, we're going to be. So actually, the extra small is the size that fits this baby, and the extra, extra small is actually too small because it's down into the eyes when it's below the mouth. So we would. So this is a very small child. And we're still using what would be the middle mask. And then how that would fit on would be just simply.

All the Velcro is sticking to everything here. So we would apply it to the baby like this. We would hold it manually and not mess with this until they have accepted it. And then we'll use the. Either the parents or your partner to help hold that mask and then put the, put the head strap around it, which is up on it. And it's a very comfortable mask for the children. I know Dr. Kadish and all the, the medics that have used CPAP on, on PEDs said that all of them has. Have accepted it really well. And then. And they, I mean, one of the children that Rob mentioned that he had was he. They were playing on their mom's phone. They were in retractions, really, really bad distress. And by the time they got to children's, they were playing on a game on the phone. So that is the equipment. There we go. So, yeah, so there's. That's Camden. That was the night of, when they brought her into City Hall. One of the funny things that she mentioned on this was that she, she put it on and she said, oh, my gosh, I remember the smell. And so we're talking about 14 years later. And she remembered, well, 10 years later from the incident. It's been about 14 years since this all happened. But she said she could remember the smell of the, of the, of the mask. But that's Rob, of course, I mentioned that earlier, and a big champion in getting this implemented and started. And then of course, from my medical sales background, I knew all the people at Palmodyne, so I connected those two together in the docs, and they basically just kept on changing protocols and getting parts and pieces that made it all work and then started the training. And that's where we're at.

So we'll open it up for questions now.

Yeah, excellent. Let me get everybody back on here. So let me do this and then let me do that and then let me see. So, Kyle, if you want, you can stop sharing so we can get everybody involved. So.

I want to start by just congratulating you for fighting for better care for kids, especially in the field.

There are many EMS systems who carry CPAP for adults, but I think never translated into kids, including my own. But it makes a lot of sense once you see the mask fit. And you can understand how by having the right equipment and equipment that's disposable, you can also start buying all these different capital type of equipment. My question to you is, what is the average cost? Because I'm sure people are starting to look at this and say, hey, it makes sense. Can you talk about cost and then talk about training? And then if you could talk about adoption, Right when you first came out and said CPAP for kids, did you get a hell no from your folks, or did you get a hell yes, we're going to do this.

Give us some insight when it comes to cost. I'm not in that division. You may know more, Dr. Kadish, or if Dr. Lowe's on, he may know more about what the cost is. If I remember right, it was like 278 bucks to get the. The one truck established, if I remember right. Yeah, around there, around that.

We're going to. We're going to reach out, see if we can get an answer for you in the next couple minutes. But we're also a little oblivious when it comes to the cost of. Of the packages that we get with the mask and the adapters.

I mean, basically, I mean, I do believe that the, you know, the generator itself, the, you know, the generator, if you're going with the Go Pap, you know, if you guys have this or the. Or the one that's orange, you know, those folks that are on here that may know the price of those, that stays the same. There is no separate packaging yet for pediatric cpap. And that's one of the things that we're trying to. Why we're doing this is. And getting it nationally because there's no demand for the manufacturers to do anything different that's specific to pediatric stuff. We have to take adult stuff and pediatric masks and kind of, you know, get the parts and pieces that make it work to make it. To make it all fit. So, like, this would go into here. So those. These are key. When it comes to any of these disposables and any of the masks right now on the market. And when it comes to pricing, I think, you know, you have to buy these, but these are probably, you know, pennies and cents, you know, maybe a dollar a piece or what have you. But if I remember right, when we set this up two years ago, it was right around like 278, $280 per truck to get three masks, a generator, and a nebulizer. And the connectors. That's ballpark.

And I love the fact that you can put the nebulizer right into the bottom of that. Let me bring in Dr. Pepe, who's an airway guru in his own right. Dr. Pepe, thoughts on. From, from the guy who, who created the word peep. What do you think?

So listen, when you talk about me being like a guru on airway that you're talking about when I'm taking airplane flights all around the country.

Right?

That's what it is. Right. So, no, but no, Peter said, I'm just for you guys sake, I am a trained, you know, originally trained as a PUL medicine and critical care doctor. And we were just so excited when CFAP came along because it helped obviate the problems of constant positive pressure, you know, positive pressure in the chest, and then because you would still be able to take your breaths and then, you know, and then, you know, have that negative swing and intra. Intrathoracic pressure. So you didn't have the kind of hemodynamic problems we had when we were applying peep in the, you know, to a ventilated patient. Now, so this is all. And I've always been in favor. We kind of always used it in children as well. But here's, you know, down to a certain age where it wasn't physically, you know, possible. But my question is, goes along with what Peter said, how was this accepted by, say, the pediatric emergency medicine staff, et cetera? But more importantly, are there state laws and different. For example, we saw this with blood that paramedics couldn't provide, you know, blood in certain states, you know, that kind of thing. So are there, you know, are there protocols that have to be done in a certain way? And is this. Do we have to sort of educate people at different places to get these on the protocols in various places? You make. Does that make sense to you, Peter, or do you know what I'm talking about?

Yeah.

Scope of practice.

Yeah. Yeah. Well, I know in Ohio and I believe everywhere else, and, and Dr. Lowe and, and Dr. Kadish can probably expand on this a little bit. The national registry, I believe, has CPAP being usable by everyone down to basic level. So when, when that comes to doing CPAP on, you know, for our scope of practice, at least in Ohio, I know for a fact that Basics and up can do adult cpap. And there's nothing specific about pediatric cpap, but the concept is the same. So it's still pressure and flow and a mask fit and that's all it is. So Dr. Kadish and Dr. Lowe may be able to talk more about that part of it.

Yeah. So in Ohio we have CPAP and it does not distinguish between adults or Pete. So.

Practice for our paramedics and our EMTs.

And then in terms of acceptance at the children's hospital, I think it's been accepted pretty openly and, and widely throughout the emergency department. One of the things, you know, we just went out to one of the stations to do a recognition this morning for a team who ended up using CPAP and who had a submergent injury. And, and one of the things that I told them is that when they bring the kid to the hospital with CPAP on the face, I think it just sort of, it, it, it sets the, the wheels in motion on that kid. So the ER is already aware that this is a sick kid. This is a kid who might need positive pressure or you know, go straight onto bipap or whatever they need. They already are sort of, they have it in their mind already that this kid is sick. And so I think it's actually been accepted pretty widely here.

All right, that's fantastic. I just wanted to make sure that's not a problem because I, I'm all for promoting this and I like the way you guys presented it today, today, showing all the different products that are out there and in a very, you know, non commercial way, etc.

Right, right.

It just was fantastic talk today. So thank you very much for this. Unfortunately, I have to roll over to another thing, but I want to maybe talk to you guys later and have you presented at our main Eagles meeting in a very short form, but I'd like to have that presented. Okay, so thanks.

Listen, thanks so much, Dr. Pepe. Let's go to George. Keith, you're on.

We cannot hear you. Nope, we still can't hear you.

Put it in the chat.

Okay.

And he did ask if there was research in children for CPAP or BIPAP in the field. And there. I've done a lit review and there is no literature right now.

In terms of, you know what the outcomes are for these children and whether it's been helpful or anything. My take, just based on the limited sort of local experience that we've had, is that we're having a lot of success with it and all these children. There's been no safety events in any of the children who come in. And so I think we're, we're moving things in the right direction here.

Yeah, it sounds like great, great type of research.

Yeah.

Marv, you're up.

Yeah, real quick, Dr. Wayne. We've been doing CPAP now for about 15 to 20 years in adults. We at ALS, we transferred it to the including BLS about 12 years ago and did a 20 patient study so that we could get the state to say, hey, yeah, BOS is great. And now it's kind of used by everybody. Our year of use has been 8, approximately 8 and above. Physically because of the need for a mask that fit better. Now that we're moving to smaller masks that do fit, we'll probably just reduce it to whatever is needed. We do permit in adults sedation because they seem to freak out a lot more than kids do. Yeah, I'm seeing Kyle agree with me. And you know, we don't even think about how often we use it anymore because we use it that much and we're using the Mercury medical device. But you know, there are lots out there. I think we cycle of whatever is most cost effective. But our BLS crews really like it in the long transports because even if they have to rendezvous, the patient is getting care initially. So yes, I think this is a great thing.

Perfect.

And Marv, you know, Marv does, for people who don't know, a lot of work on airway and you can typically see Marv sitting in front of a cadaver teaching folks at the all the national conferences. So Dr. Wayne, thank you for that. I'm going to go to my co host because Tanner, the reason I bring him on here is because he's wicked smart, but he's also going to bring in the research aspect of it. So Tanner, I see you've been posting some links already. Take it away, my friend. What do we got?

Sure, yeah.

So I think from at least my perspective, right, there's very few interventions that we can offer in the pre hospital setting that have really been conclusively shown to impact patient outcomes. And CPAP definitely is one of those interventions. There's actually even a Cochrane review out there of randomized controlled trials that shows in adult patients it decreases the need for ICU admission.

Inhibition and Even mortality. And for mortality, I think the number needed to treat in patients with acute heart failure syndromes is something like 17. So very low compared to most medical interventions that exist out there. And so when we have an intervention that we can deliver that's been studied repeatedly and shown to have patient important benefits in multiple different populations, I think it's important to deliver this intervention to as many eligible people as possible, which of course includes pediatric patients and the national association of EMS Physicians. This is the link that I put in the chat. They actually have a position statement that recommends consideration of CPAP and BIPAP in this patient population. And I think they kind of temper it, they say with consideration of system constraints, operational constraints, and they cite some in hospital literature focusing specifically on ICU patients with asthma, bronchoconstriction, lower airway disease that shows similar to the adult literature, decreased need for innovation in pediatric patients that were randomized to non invasive positive pressure ventilation. So, and I will say that, you know, as West Virginia, working in West Virginia as part of the statewide EMS system here, we are also limited. We can only provide CPAP to patients who are greater than 12 years of age. But I think definitely with our next round of protocol updates, this is definitely something that we need to take a look at and raise to our MPCC and see if we can get our state protocol changed. So thank you both for sharing your stories and your expertise.

One of the things I do want to share real quick before we have to roll is just to go back to Dr. Antevi's question about acceptance. Was it oh, why are we doing this? Or oh yeah, we're doing this. It was kind of middle of the road for all the people that we talked to, a couple of people, like I mentioned, one nurse in an ER said that, boy, that's being really aggressive. Kyle, I don't know if we're going to go with CPAP at my department yet for kids. And I'm like, well, it's very non invasive, so I'm not sure how aggressive you think it is. It's giving support. We do it in the hospital setting for years. We're just now have the parts and pieces and the masks that we can now get into the EMS setting. And then it made her question, it made her go, oh, okay. So we, and once again, you know, we talked about CHF and what it does with adults. But remember that this is those pictures of and those videos of those kids earlier. Those are the kids that are screaming for that positive pressure support. And the ones that Are they're doing everything they can to support themselves and you don't know when they're going to crump. And that's the kid that we really need to focus on who needs the cpap. And that's the biggest problem that we're having right now is I've got crews that I ask them, hey, you had a pediatric respiratory problem the other day. Tell me all about it. And they'll. They'll talk all about it. Like, was there retractions? And they'll say, yes. I'm like, did you use cpap? They're like, no, they weren't that bad. There was retractions. That's bad. I don't have retractions. A normal child doesn't have retractions. That is bad. Retractions is bad. Grunting is worse. Nasal flaring is bad. You know, sub sternal, subcostal retractions, all bad. That one child that was sucking his. The middle of his xiphoid process, process into the back of his chest, that's bad. We can support these kids. So we have. The biggest problem is changing the mindset of the clinician who we all know that pediatrics, for whatever reason, we all get nervous. And I did it six, you know, 14 years ago. I was nervous that day that I saw my daughter so sick. And I'm a, you know, I'm a. I'm a firm believer in we need to be somewhat aggressive in applying, you know, positive pressure to these kids that look like the videos that you saw. Because that's what we have now. Non invasively to support them where before it was just diesel fuel.

Yeah, this is great commentary. I love it. Non invasive. Right. So I want to bring in someone who's been a great friend of the podcast. He's been on the podcast before and quite frankly, we R and D from him, which is we rip off and duplicate many of the things he does, which is Gordon Miller in Desoto Parish in Louisiana. So Gordon's been using T1, the Hamilton T1. We stole that idea and now we're using it. He's of course been doing CPAP in kids. So I pinged them like, Gordon, I'm bringing you on the show. So, Gordon, welcome again to the show. And please make some comments on what you heard today from Dr. Kadish and from Kyle.

Yeah, it's a great discussion. The one thing, and we're crazy busy right now. I'm at work, so I'm just going to kind of shoot over some things real quick. Whatever device you're using, be very careful with what you're stacking onto it and creating dead space. For pediatrics. You don't want them rebreathing CO2. That's a lot of primary concern with ours. We have pediatric circuits, things like that. On the T1 primarily, we're going to be bipapping those patients. We use CPAP to some extent. Maybe near drowning drowning, stuff like that, maybe. But BiPAP is usually our go to asthmatics. We'll be giving small non disassociative doses of ketamine with that. That works great for the bronchospasm as well. And also glycopyrrolate to mitigate the bronchorrhea and also the hypersalivation.

Mask. Equipment size is very important. The good thing about the T1 is I get to monitor pressures and all that. So it's very safe. Like they said, don't be scared to use pressure on kids. If we have areas in the lung that have shunted, we need to get oxygen back in those areas, get those areas perfusing again. So we don't have a bad VQ mismatch. You know, we don't want that whole lung to end up shunning in it. With a pulmonary hypertension situation. We have had fantastic results on it. We've been doing this for right at nine years now. I can say nothing but good results from it. If we're preventing intubations, absolutely. Staving off risk, don't be scared to use it. I tell our cruise a lot, jump on it fast, because I can guarantee you nine times out of 10, you get to that house and you know a lot of people that want to grab a neb treatment, well, guess what? The parents were like, how many neb treatments do you get A box, you know, four or five. Nobody ever gets there and said, oh, we gave them one treatment. They're this bad. So they called us because that's not working. So we need to step in and do something else.

Just to be clear, for everyone's knowledge here, the T1 is something separate. What Kyle and Chelsea showed us today doesn't require ventilator. It just requires equipment that comes in a little bag, requires the correct mask. So, Gordon, what you're doing is kind of like a higher level intervention. But what we're recommending that people at least consider is that basic old CPAP that is now you're probably carrying it already. Now you just have to buy a couple of adapters, buy this smaller mask, mask sizes, not just one, one size. And do the training and you're, and you're ready to go. So my last question before we go is as far as the training and implementation time, everyone you have here on the call, they hear all these ideas, but the very first thing in their mind is, how long will it take me to roll this thing out? Are we talking an hour, are we talking four hours? Or is it just an info bowl saying, hey, start doing this? Obviously we're not going to do that. But what are your thoughts? Chelsea and Kyle ON well, when we.

When we implemented it, when we implemented it, we, we do our training through a shift clinical educator and I'm one of those. And we go out to the station level with an hour, typically an hour education process. And we, we did a, we did a pediatric respiratory distress lecture with CPAP thrown into it with the parts and pieces with the baby with the mask so people can touch and feel and put things together. And by that end of that hour where we gave them the kit and said, you are now qualified to start your CPAP if you get a kid in one minute from now. So the training on it, the biggest thing is we've done, when, we've now done it twice. We did it two years ago and then we did it again just last month. And the biggest change that I made during that lecture was very hitting home that respiratory distress visual of that child grunting, retracting the child that needs that. The one child that we talked about, I talked about a minute ago, they said that the mom said that the baby was grunting or not grunting, doing that type of breathing, retractive breathing for over 24 hours. And, and, but their, their pulse ox was in the mid-90s and that's still not great, you know, so it was still one of those things. Like we could have really supported that child for the 25 minute trip down to Children's and by implementing, you know, pediatric cpap. If we got into that mindset of that look, any type of retractions is, is, is the key to putting CPAP on that respiratory distress PA Pediatric.

Yes.

Awesome. I was going to give Chelsea and Rob the last word. Go ahead, take it away.

I was going to say we did the same one hour training. We did it as a video asynchronous to roll it out and then followed it up shortly after that just to increase adoption with some in station training. And that's been the goal. She mentioned today that we were out at a station congratulating them is just as that word gets out on the good use has been, has been increasing our adoption quite well.

So I think one of the we also rolled it into core competencies at Delaware county as well. I think using that as like a scenario for the pediatric case that year was an asthmatic who needed to get, you know, the goal was to get the team to put the kid on cpap. And so just reinforcing that. That CPAP is a tool in your toolbox.

I tell you, I love all of this. And I think that you guys presented it in a way that's very easy. It's nothing really new conceptually. It's just that we have to kind of have our minds open to the fact that it can be given to child of any age. Just got to know how to use it, when to use it, know the contraindications train on it. And you could really prevent a child from being intubated. You know, here in Florida, we have a lot of drownings. And as many of you know, many of those drownings are not in cardiac arrest, but they are in respiratory distress. And oftentimes they sit in our ER for, you know, six hours and they go home and some of them have to stay the night. But.

It'S a perfect type of patient who you will get there. The child is grunting, is in distress, and this is a perfect application rather than waiting. And I have these visions in my mind because I've done some medical expert and where you see a child who's been grunting and it's all on body cam and they've done nothing. And you say to yourself, my goodness, for that 45 minutes, if that child would have gotten some positive pressure, it would have been really nice. So.

I'm going to close it down because I'm getting a medical right now. But thank you all so much for joining me today. And Tanner and join the webinar on the right hand side, Dr. Peppy's Webinar. And again, thank you, Chelsea Kyle, for joining us and have a great weekend, everybody.

Thanks for having us. Have a good weekend.

Take care. Bye, guys.