Candidate Name: _________________________________________ Date: ______________________

Examiner Name and Signature: _________________________________________________________

Time Started: __________ Time Ended: __________ Points: _____/37 PASS/FAIL (Circle One)

Points Possible Points Awarded
Prepares patient              
    Takes or verbalizes appropriate PPE precautions            1
    Assures adequate blood pressure            1
    Positions patient in a position that will optimize ease of ventilation (high Fowler’s)            1
Assesses patient to identify indications for CPAP          
    Congestive heart failure, COPD,  asthma, pneumonia, pulmonary edema, near drowning            6
Assesses patient to identify absolute contraindications for CPAP          
Unconscious/unresponsive, inability to protect airway or inability to speak, inability to sit up, respiratory arrest/agonal respirations, nausea/vomiting, hypotension (systolic blood pressure <90mmHg), suspected pneumothorax, cardiogenic shock, penetrating chest trauma, facial anomalies/trauma/burns, closed head injury, active upper GI bleeding or history of recent gastric surgery (1 pt for each assessed)           12
Relative contraindications              
         History of pulmonary fibrosis            1
         Decreased LOC            1
         Claustrophobia or unable to tolerate mask (after first 1-2 minute trial)            1
Selects, checks, assembles equipment          
    Assembles mask and tubing according to manufacturer instructions            1
    Connects CPAP unit to suitable O2 supply/ensures oxygen is flowing            1
Performs procedure          
    Places mask over mouth and nose (leaves EtCO2 nasal cannula in place)            1
    Titrates CPAP pressure (based on local protocols/device dependent)            1
    Coaches patient to breathe normally and adjust to air pressure            1
Frequently reassesses patient for desired effects/goals of CPAP          
Decreased or elimination of dyspnea, decreased respiratory rate, decreased heart rate, SpO2 >92%, stabilized blood pressure, absence of complications e.g. barotrauma and pneumothorax (1 pt for each assessed)            5
In the event of Failure to Improve:          
Should patient fail to show improvement with CPAP, asw indicated by sustained or increased heart rate, Respiratory rate or blood pressure or by a decrease in level of consciousness remove CPAP device and assist ventilations with BVM or ETI as needed            3

                                        Points Possible: 37 Total Points Awarded_______________

Critical Criteria

●      Failure to list 10 of the 15 absolute/relative contraindications

●      Failure to list desired effects/Goals of CPAP

●      Failure to identify potential complications (Barotrauma, Pneumothorax)

●      Failure to properly assemble the device

●      Failure to frequently reassess the patient after application of the CPAP device

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