Abstract:
A medication delivery apparatus and method for a continuous positive airway pressure (CPAP) system such as used in emergency treatment of severe respiratory distress. The apparatus of the invention includes a 3-port Tee fitting, one port of which is connected to the inlet port of a CPAP face mask operable at an elevated pressure. A second port is connected to a CPAP gas conduit supplying an oxygen-containing gas at a pressure above atmospheric. The third port is connected to a flexible tube receiving aerosolized medication from an upper outlet of an openable/refillable lightweight nebulizer. The flexible tubing is only long enough to bend vertically downward to support a lightweight nebulizer in a vertical attitude, whereby full nebulization takes place, no medication is spilled, and the tubing length is minimized for maximal transfer of medication to a patient. In addition, cutting of the CPAP gas supply tube and placement of a T fitting between the cut ends, with its concomitant wastage of condensed medication, is avoided. The patient head does not need to be in an upright position. The patient&#39;s airway is continuously maintained at an elevated pressure to maintain an open airway and oxygenate the patient, permitting repeated doses of nebulized medications at independently controlled nebulization rates, minimizing downtime of both the pressurized oxygen and aerosolized medication.

Description:
BACKGROUND OF THE INVENTION  
       [0001]     1. Field of the Invention  
         [0002]     The present invention relates to a device and method for injecting a medication into a pressurized pulmonary respiration system. More particularly, the invention relates to a medication delivery device and method for pulmonary dosing in a Continuous Positive Airway Pressure (CPAP) system.  
         [0003]     2. Background of Related Art  
         [0004]     Many respiratory conditions and diseases exist which are treatable by the administration of oxygen or oxygen-enhanced air. Several examples of such are Chronic Obstructive Pulmonary disease (COPD), congestive heart failure (CHF), and asthma. Asthma is sometimes categorized as a COPD.  
         [0005]     Chronic Obstructive Pulmonary disease (COPD) is a condition in which a patient&#39;s lung has limited elastic recoil and/or the alveoli and terminal bronchioles have stiffened with scar tissue. The terminal bronchioles may collapse during exhalation, leading to air trapped in the alveoli. The disease causes much discomfort inasmuch as a patient must work hard to breathe, and physical exercise is difficult.  
         [0006]     Congestive heart failure (CHF) may result in “preload” in which the blood sent to the left ventricle by the lungs exceeds the heart&#39;s capacity. Alternatively, the pressure against which the heart is pumping may be excessive, a condition called “afterload”. As a result of either or both conditions, a patient will lose the ability to absorb oxygen and get rid of carbon dioxide.  
         [0007]     In any of the pulmonary diseases and conditions, a loss of oxygenation may reach a critical state requiring emergency treatment. Typically, emergency treatment must begin without delay, and equipment and medicinals for administering treatment are normally available in an emergency vehicle such as an ambulance. Depending upon the particular disease and condition of the patient, one or both of oxygenation and medication are commonly applied.  
         [0008]     Other relatively common respiratory conditions exist, including for example, apnea, in which a patient has an absence of breathing. When it occurs during sleep, the condition may be fatal.  
         [0009]     In addition to specific medicinal treatments, emergency treatment of respiratory distresses may include one or more of resuscitation, opening of an airway blockage for ventilation, and oxygen enhancement via nasal catheter, mask or endotracheal catheter. More complex systems are capable of increasing ventilation and oxygenation of a patient during the inhalation portion of the breathing cycle, but because of their complexity are not generally made available to emergency medical technicians (EMT&#39;s). An example of such a system is a Bi-level Positive Airway Pressure (BiPAP) system, in which a respiration machine senses the onset of a patient&#39;s inhalation cycle and elevates the pressure in the patient&#39;s airway for enhanced inhalation. The exhalation pressure is typically reduced.  
         [0010]     The numbers of medical personnel in an ambulance is typically very limited, and the purpose is to transport a patient to a permanent medical facility quickly, performing only basic medical procedures required to protect the patient&#39;s life. Even a relatively minor invasive procedure such as ericothyriodotomy is not performed in a pre-hospital setting unless absolutely necessary to the life of the patient. Typically, such a procedure is an advanced skill performed by a medical doctor, flight nurse, or paramedic. This is not a skill performed by an emergency medical technician (EMT), as governed by standards of the profession. Currently, endotracheal intubation is indicated when a patient cannot oxygenate himself adequately, the “gag” reflex is gone, or a patient&#39;s breathing has stopped. In endotracheal intubation, a patient&#39;s airway is visualized, and a tube is inserted. Breathing is then taken over by manual assistance or mechanical ventilator. Hazards associated with endotracheal intubation include hypoxia, aspiration, trauma to the airway, and an acquired dependency of the patient to the ventilator. Therefore, intubation is generally not performed unless absolutely necessary.  
         [0011]     In the practice of respiratory treatments, available face masks are designed to provide oxygen/air through the mouth and nostrils of a patient, and assume that in the event a nebulized medication is to be administered, the patient&#39;s head and upper body will be raised i.e. substantially upright. Thus, the centerline axis of the mask&#39;s inhalation port is substantially parallel to the patient&#39;s longitudinal axis, i.e. nearly horizontal when the patient is in a supine position. A nebulizer&#39;s outlet is constructed to fit rigidly into the mask&#39;s inhalation port, and a patient is supported in an upright position during the administration. However, in an emergency situation in which the patient&#39;s condition (severe injury/illness) requires a supine position, a way must be found to administer a nebulized medication at a controllable rate and without undue stress to the patient. Attempts to administer a medication aerosol to a face mask of a supine patient may result in non-delivery and wastage of a substantial portion of the medication due to flooding of the nebulizer. The un-aerosolized medication may be carried over into the mask and discharged. Thus, a patient is deprived of much of the medication.  
         [0012]     In emergency medical pre-hospital situations, time is usually a critical factor. Typically, emergency i.e. pre-hospital personnel make a rapid diagnosis to determine what procedures are required to maintain life and prevent patient deterioration during transit to a treatment center, e.g. hospital. Emergency personnel must determine whether respiratory treatment is indicated, and if so, whether the indicated treatment is to be minimal, such as the simple application of a stream of oxygen or oxygen-enriched air ( e.g. such as 21-90 percent oxygen) by mask or nasal cannula, or when a more invasive technique requiring endotracheal intubation is indicated.  
         [0013]     In most breathing emergencies, a variety of medications such as bronchiodilaters (e.g. albuterol) may be indicated, depending upon the diagnosis protocol. Providing oxygen through an endotracheal catheter has a number of disadvantages relating to simultaneous or co-medication of the patient. In order to apply an aerosolized medication, the endotracheal tube may be removed from a ventilatory source to inject the desired medication. Often, multiple doses of more than one type of medication may be required, leading to less than optimal ventilation/oxygenation as well as irritation of the patient&#39;s throat. In some emergency situations, continuous application of both oxygen and medicinals may be indicated, in which case the emergency personnel must attempt to provide both oxygen and medicinals with minimal downtime for each. In some cases, adequate oxygenation/respiration and adequate medication delivery cannot be both maintained, leading to extreme stress to the patient, and deterioration of the patient&#39;s condition.  
         [0014]     In the past few years, another technique has been developed which is intermediate simple oxygenation and the more radical procedures requiring endotracheal intubation. The method has been used for many years in some fixed installations (e.g. hospital emergency rooms) but not generally in emergency vehicles. This method is known as Continuous Positive Airway Pressure (CPAP) and is appropriate for patients suffering severe respiratory distress for which normal oxygenation/respiration at atmospheric pressure is less than effective. Prior to the availability of emergency CPAP treatment, the patient was typically subjected to endotracheal intubation, a much more invasive procedure. A current protocol for the use of CPAP is summarized in a reference in PARAMEDIC 01/03, page 3C entitled CPAP.  
         [0015]     In the CPAP method, a continuous positive internal pressure is applied to the patient&#39;s airway during both inhalation and exhalation. As shown in  FIG. 1  of the drawings, a simple CPAP apparatus  100  of the prior art includes an oxygen source  102  capable of delivering a pressurized stream of oxygen  104  or oxygen diluted to a lower concentration, such as for example 25-90 percent. A gas diluting apparatus  106  may be used to dilute a nearly pure oxygen stream  104  with filtered atmospheric air  108  to a desired concentration using aspiration, thus reducing the weight of pressurized gas which must be carried aboard an emergency vehicle. A tightly-fitting mask  110  is required to prevent undue leakage at the mask-face interface  134 , and to maintain a desired airway pressure. The CPAP face mask  110  has an inhalation port  112  and an exhalation port  114 , the latter having a Positive End-Expiratory Pressure (PEEP) valve  116  which maintains a positive pressure in the mask and patient&#39;s airway. Often, a filter is incorporated into the PEEP valve  116  to prevent escape of exhaled fluids, etc. into the atmosphere. The maintained pressure is typically between about 5 cm. water and about 15 cm. water but may be higher or lower, for example, from about 2 cm. water to about 30 cm. water, or even higher, depending upon the pressure requirement for maintaining the airway of the patient in an open condition. This pressure offsets (at least partially) the pressure against which the patient must work to inhale, and maintains an open airway in exhalation. In COPD patients, the enhanced pressure prevents collapse of the terminal bronchioles, enhancing the exchange of oxygen and carbon dioxide. In a patient experiencing congestive heart failure (CHF), the enhanced constant pressure decreases myocardial workload while nitroglycerin is administered to dilate the arteries. Arterial dilation reduces both preload and afterload on the heart.  
         [0016]     A Continuous Positive Airway Pressure (CPAP) treatment protocol is being considered for widespread use by emergency vehicle EMT-rated personnel, inasmuch as this method may avoid the use of invasive endotracheal intubation by endotracheal catheter. In addition, the CPAP method is straight-forward, does not require complex equipment, and is relatively easy to pre-indicate, administer, and moniter. Although CPAP has been used in hospital settings for years, the method has now been very successfully tested in some emergency vehicle venues for administration by EMT-rated personnel. General information regarding the CPAP methods and proposed use in emergency vehicles is provided in Use of CPAP and BiPAP in Acute Respiratory Failure, pp. 1 and 2 (author unknown), found at http://www.theberries.ns.ca/archives/CPAP.html.  
         [0017]     The administration of an aerosol medication while maintaining a CPAP positive pressure of air or oxygen-enhanced air in the patient&#39;s airway represents a drawback of the current CPAP method. Typically, to dose with a medicinal aerosol, the pressurized mask is temporarily removed, and medication administered by a hand-held nebulizer or through a nebulizer mask until the medication  160  in the nebulizer jar  142  is depleted, at which point the hand-held nebulizer is removed and the CPAP mask reattached and started for oxygenation/ventilation.  
         [0018]     Optionally, the CPAP oxygen/air stream is disconnected from the CPAP face mask and replaced by a nebulizer outlet port. Thus, the aerosol is introduced during a time when gas pressure may be insufficient to keep the airway open, or the quantity of oxygen may be too low. As a result, much of the medication may be wasted. Furthermore, the period without positive pressure may significantly reduce ventilation/oxygenation, i.e. starving the patient of oxygen. Thus, a loss of positive pressure during the medication administration period may have serious consequences. In current practice, nebulisation of a single medication dose may take up to 3-4 minutes or longer.  
         [0019]     In addition, this method requires the patient&#39;s head to be in an upright, i.e. erect position, as described in a protocol in PARAMEDIC 01/03 entitled Pulmonary Edema. This position may be difficult to attain or maintain, and tipping of the nebulizer container e.g. jar  142  from a vertical position may have deleterious medical consequences. If a patient&#39;s head is not kept upright (see prior art  FIG. 3 ), the nebulizer (firmly attached to the mask) will be tipped from a normal vertical position, interrupting or reducing gas flow through the medication. Aerosolization of the medication will cease or become reduced. Furthermore, tipping of the nebulizer container  142  may allow the liquid medication to flow from the nebulizer outlet without being aerosolized.  
         [0020]     An improved procedure has been proposed by Keith Wesley, MD, in MASK CPAP FOR THE EMT-BASIC in EMS Professionals, May-June, 2003, pp. 1-3 whereby the nebulizer is positioned in-line with the bulk CPAP oxygen stream, using the oxygen stream to nebulize the medication, as depicted in Prior Art  FIG. 3 . However, this method prevents independent control of (a) the flowrate and pressure of the CPAP oxygen-enhanced stream and (b) the flowrate and nebulizer pressure drop of the nebulizing stream. This method may limit the total gas flow rate to the capacity of the nebulizer, which may be inadequate for proper CPAP operation. In addition, this method requires that the patient&#39;s head  150  must be positioned in a substantially upright position. Such is not always possible in a pre-hospital emergency situation because of injuries and/or illness, limited time, limited personnel, limited equipment, and/or for other reasons. As illustrated in  FIG. 3 , when the nebulizer cannot be maintained in a “top-side up” vertical position, liquid medication will not be aerosolized and may be largely wasted. The Wesley reference points out that in the recommended procedure, faster nebulization occurs, but “some of the medication condenses in the tubing or leaks out the PEEP valve”.  
         [0021]     U.S. Pat. No. 4,020,834 dated May 3, 1977 to Bird discloses a respiration apparatus for treating patients in a BiPAP manner, maintaining a positive pressure during exhalation and substantially atmospheric pressure during inhalation. The apparatus and its operation are very complex. The administration of medication in a Continuous Positive Airway Pressure (CPAP) apparatus is not in view.  
         [0022]     U.S. Pat. No. 5,287,849 dated Feb. 22, 1994 to Piper et al. discloses a medicinal aerosol delivery system for a patient&#39;s lungs. The apparatus is directed to endotracheal use and is not meant for use in a CPAP operation.  
         [0023]     U.S. Pat. No. 6,805,118 dated Oct. 19, 2004 to Brooker et al. describes a pulmonary dosing system and method in which a medication is administered in pulsed doses entrained in air. The administration to a patient continuously maintained at a positive pressure is not in view.  
         [0024]     None of the cited prior art documents patents provide a method for administering a medication during CPAP respiration in which the patient&#39;s head is in a non-upright position. None of the cited art overcomes the problems presented by administration of a medicinal aerosol to a patient undergoing emergency CPAP therapy, such problems including patient stress resulting from excessive time without positive pressure, insufficient exposure to medication aerosol, dumping of the liquid medication into the mask or mouth, and other incidents which may likely occur.  
         [0025]     Efforts to overcome the disadvantages of the prior art with respect to the administration of medications during emergency CPAP have led to the effective apparatus and methods of the invention which are herein described, illustrated and claimed, infra.  
       SUMMARY OF THE INVENTION  
       [0026]     The present invention is apparatus and method for administering a medicinal aerosol to a patient undergoing Continuous Positive Airway Pressure (CPAP) respiration. The apparatus and method are typically applicable in what are considered emergency events.  
         [0027]     In CPAP, a tight-fitting mask is used to eliminate or minimize leakage between the patient&#39;s face and the mask. The CPAP mask includes means for controlling the pressure in the mask at a constant or varying elevated pressure such as between 1 and 50 cm. water (above atmospheric pressure), so that the patient is forced to inhale with, and expire against the positive pressure. A source of oxygen or oxygen-containing gas (e.g. air) is provided at a pressure greater than the mask pressure to ensure that a desired oxygen concentration is continuously available to the patient&#39;s airway and lungs at a pressure which maintains an open airway.  
         [0028]     In contrast to the prior art, a medication delivery device of the present invention includes a three-port Tee fitting, one port of which may be fitted into the inlet port of a CPAP mask. The bulk stream of oxygen-containing gas is connected to another port of the Tee fitting. A flexible corrugated tube connects the remaining port of the Tee fitting to the outlet of a medication nebulizer. In the nebulizer, a stream of pressurized gas, typically an oxygen-containing gas, aerosolizes a medication placed in the nebulizer container. The nebulized medication and gas passes through the flexible corrugated tubing (aerosol conduit) and is mixed with the CPAP oxygen/air stream and introduced into a CPAP mask maintained at an elevated pressure. The nebulizer has a supply of oxygen, air, or other gas which may be independent of the CPAP oxygen source. The gas supply stream to the nebulizer is controlled at a flow rate which provides a desired nebulization rate independently of the flowrate of the CPAP oxygen stream. The generated medication aerosol is directed from the nebulizer into the aerosol conduit. The aerosol conduit or delivery tube is of a sufficient length and flexibility such that the nebulizer may be positioned and maintained in an upright attitude irrespective of the attitude of the patient&#39;s head or CPAP mask. Preferably, the aerosol conduit is connected to the side port of the three-port Tee fitting, to position the nebulizer laterally from the patient&#39;s head. It is advantageous to provide an aerosol delivery tube with minimum length, to minimize condensation of aerosol in the cold tube. An aerosol delivery tube length of about 5-10 cm. is considered to be minimal for permitting a  90  degree bend downward from the horizontal, for an upright nebulizer. More generally, the length of the aerosol conduit may be about 4 cm. to about 50 cm., although even longer lengths may be necessary in some circumstances where the nebulizer cannot be placed any closer to the patient. In general, the tube length is preferably as short as possible within the constraints of available space and the necessity for the nebulizer to be upright and readily accessible.  
         [0029]     In one embodiment of the medication delivery device, components generally available on an emergency ambulance vehicle may be assembled to provide the complete apparatus. For example, the medication delivery device may be formed by serial attachment of the following conventionally available components: (a) three-port Tee fitting, (b) medicinal delivery tube(aerosol conduit), (c) tube-to-nebulizer adapter, (d) nebulizer with medication container and gas inlet, and (e) nebulizing oxygen tubing connected to a pressurized oxygen source reduced to a desired nebulizing pressure, e.g. about 5-100 inches water. The nebulizing pressure is a function of the CPAP mask pressure, the nebulizer design (affecting pressure drop), and the nebulizing rate to be maintained. Typically, the oxygen source is a high pressure gas cylinder to which a pressure regulator is connected for maintaining a controlled outlet pressure at which the desired rate of aerosolization will occur.  
         [0030]     In another embodiment of the invention, the device is formed as a unit and does not require adapters for connecting the various components. For example, the Tee fitting and medicinal tube may be formed as one piece, and the medicinal delivery tube (aerosol conduit) may be formed with an integral end configured to join with the nebulizer outlet. Thus, emptied nebulizers may be quickly removed and replaced by filled nebulizers (of the same or differing medication) in a few seconds.  
         [0031]     In one embodiment, the Tee fitting is separable from the rest of the device, so that the delivery tube of the device may be connected directly to the inhalation port of a conventional nebulizer mask.  
         [0032]     In one embodiment of the invention, the steps used in the method of the invention may be generally characterized as (a) providing a CPAP apparatus with an oxygen or oxygen/air supply conduit and a tightly fitting CPAP mask having an inlet port and an outlet port with a pressure controller capable of maintaining a continuous positive pressure in a patient&#39;s airway, (b) connecting a third port of a three-port Tee fitting to the CPAP mask inlet port (inhalation port); (c) connecting a second port of the three-port Tee fitting to the oxygen/air supply conduit, (d) providing a flexible aerosol delivery tube with inlet and outlet ends; (e) connecting one end of the aerosol delivery tube to the first port of the Tee fitting; (f) providing a medication nebulizer with a medication jar (container), oxygen inlet port and aerosol outlet port; and (g) connecting the other end of the aerosol delivery tube to the nebulizer outlet aerosol port. A combined flow of oxygen-containing gas and medication aerosol is then provided to the patient by (h) providing a pressurized oxygen-containing gas (via oxygen/air supply conduit) at a desired rate to the Tee fitting, (i) independently introducing a gas to the nebulizer oxygen inlet port at a desired rate to form and provide a medication aerosol to the Tee fitting, and (j) setting the PEEP on the outlet port of the mask to maintain a desired continuous positive pressure within the mask and patient&#39;s airway. It is understood that the order of the steps of the method may be varied as long as the apparatus as described is formed and then operated to provide a substantially continuous stream of oxygen-containing gas and aerosolized medication to a continuously pressurized mask.  
         [0033]     It has been found that the nebulization rate is highly controllable, and higher rates are possible when compared to various methods of the prior art. When empty, the nebulizer container may be opened and refilled without shutting down the CPAP gas flow, or the CPAP gas flow may be shut down for a very brief period, such as for example, about 10 to about 20 seconds, to exchange a filled nebulizer container for the empty container. Thus, the administration of positive pressure oxygen-containing air (ventilation) and administration of medication aerosol are conducted substantially simultaneously rather than sequentially. Where a patient requires a medication (or medications) on a continuous basis, administration of the medication can be performed without significant suspension of the CPAP operation during either medication delivery or nebulizer refill.  
         [0034]     All of the CPAP operations including medication delivery are generally within the scope of an EMT&#39;s duties, not requiring an attending physician or paramedic.  
         [0035]     Other features and advantages of the present invention will become apparent to those of skill in the art through consideration of the ensuing detailed description, the accompanying drawings, and the appended claims. The drawings contain idealized representations for better illustration of the apparartus and methods of the invention, and various elements of the prior art are not necessarily shown, and dimensions may not be shown to scale.  
     
    
     BRIEF DESCRIPTION OF THE DRAWINGS  
       [0036]     In the drawings, which depict exemplary embodiments of the prior art and various features of the present invention:  
         [0037]      FIG. 1  is a generalized perspective view of a PRIOR ART exemplary continuous positive airway pressure (CPAP) system to which the present invention is directed;  
         [0038]      FIG. 2  is a perspective view of a PRIOR ART apparatus for administering a medicinal aerosol into a CPAP mask during oxygen administration;  
         [0039]      FIG. 2A  is a perspective view of a PRIOR ART apparatus for administering a medicinal aerosal into a CPAP mask wherein shutdown of the CPAP oxygen flow is required during medicinal administration;  
         [0040]      FIG. 3  is a perspective view of a PRIOR ART method for administering a medicinal aerosol into a conventional nebulizer face mask worn by a supine i.e. face-up patient;  
         [0041]      FIG. 4  is a perspective view of an exemplary CPAP apparatus to which a medication delivery device of the present invention is attached;  
         [0042]      FIG. 5  is an exploded view of a medication delivery device in accordance with an embodiment of the present invention;  
         [0043]      FIG. 6  is an exploded view of a circular portion  6  of  FIG. 5 , in which a connections to ports of a 3-port Tee fitting are varied in accordance with another embodiment of a medication delivery device of the invention; and  
         [0044]      FIG. 7  is a perspective view of a medication delivery device of the invention connected to a conventional nebulizer face mask worn by a supine patient.  
     
    
     DETAILED DESCRIPTION  
       [0045]     The present invention comprises an apparatus and method for administering a nebulized medication into a patient undergoing emergency oxygen therapy in which the patient&#39;s airway is continuously subjected to an elevated pressure during both inhalation and exhalation cycles. The oxygen therapy method is commonly known as Continuous Positive Airway Pressure (CPAP). In the past, it has been largely used in hospital settings. CPAP has now been approved in some states for use by Emergency Medical Technicians (EMT&#39;s) without the attendance of physicians or paramedics, such as in emergency vehicles (e.g. ambulances). The CPAP method provides an effective and advantageous alternative to invasive tracheotomy surgery and endotracheometric intubation. The method utilizes some of the same equipment used in simple mask oxygenation.  
         [0046]     In CPAP, the face mask pressure of a patient is typically preset or adjusted within a broad range from about 1 cm. H2O to about 25 cm. H2O (or higher) above atmospheric pressure. In most cases, the airway pressure is controlled at between about 2.5 cm. H2O and 12.5 cm. H2O, which is sufficient to maintain the airway in an open condition. The concentration of oxygen in the incoming gas usually exceeds that of air, i.e. &gt;21 percent, and normally may be in a range between about 25 percent and 99 percent oxygen.  
         [0047]     A generalized prior art CPAP apparatus  100  exemplary of the current state of the art is shown in  FIG. 1 . The CPAP apparatus  100  includes an oxygen source  102  which provides oxygen at an elevated (i.e. positive) pressure and a controllable flowrate. The oxygen gas from source  102  may be supplied at a desired pressure and rate by what is commonly termed a respiration machine, not shown. The pressure of oxygen gas from the respiration machine is somewhat greater than the pressure at mask  110 , to overcome the pressure drop through second conduit means  130 . In some cases “pure” oxygen of about 90+ percent oxygen is diluted on-site to a desired lower concentration by atmospheric air.  
         [0048]      FIG. 1  shows the major elements of a conventional PRIOR ART Constant Positive Airway Pressure (CPAP) apparatus  100  in simplified form. These elements include an oxygen source  102 , a first conduit means connected to the oxygen source  102  by fitting  125 , and first conduit means  128  connected to inlet port  124  of dilution device  106 . Pressurized oxygen from source  102  is transported to dilution device  106 , which may include an aspirator which draws in atmospheric air  108  through inlet  132  and filter  132 A to dilute the “pure” oxygen. Diluted pressurized oxygen  158  then flows from outlet  126  through second conduit means  130  to the inlet i.e. inhalation port  112  of a tightly-fitting mask  110 . The second conduit means  130  is typically formed of flexible (generally corrugated) plastic tubing with non-corrugated ends  131 A and  131 B. The CPAP mask  110  has an exhalation port  114  into which may be fitted a Positive End Expiratory Pressure (PEEP) valve  116  to maintain the desired airway pressure within the mask  110 . The PEEP valve  116  may be limited to a single mask pressure such as 5 cm. water, or may be controllable at one of two or more pressure settings (e.g. 5, 7.5 and 10 cm. water. If desired, the actual pressure within the mask  110  may be monitored by means known in the art. CPAP mask  110  is shown with straps  122  for firm attachment to a patient&#39;s head  150 C (see  FIG. 3 ), thereby preventing significant gas leakage at the mask-to-face interface  134 .  
         [0049]      FIG. 2  illustrates another PRIOR ART CPAP medication system  100  which is used in ambulance service. The CPAP system  100  is shown with an oxygen source comprising a wall outlet  127 . First conduit means  128  has a connector  125  which sealingly fits into the wall outlet  127  for passage of oxygen to an oxygen dilution device  106 . The dilution device  106  has an air inlet  132 A for entrance of dilution air  108  through filter  132  The dilution device  106  is connected to a second conduit means  130  which typically comprises a substantial length of nominal 1-inch OD flexible corrugated plastic tubing. One end  131 B of the conduit means  130  is connected to the inhalation (inlet) port  112  of a CPAP mask  110 . For dosing with an aerosolized medicinal  162 , the conduit means  130  is cut and two Tee ports of a Tee fitting  163  connected to the cut ends  133 A,  133 B. A nebulizer  140  is connected to a side Tee port of the Tee fitting  163 . The nebulizer  140  is configured so that the oxygen/air flow  158  (i.e. the CPAP gas) is passed through the nebulizer  140  to aerosolize the medication. There are major disadvantages to this system, including the following: 
    (a) The conduit means  130  must be cut and both cut ends fitted to a Tee fitting  163 , taking extra time in an emergency situation;     (b) The system requires that the nebulizer  140  be placed (or held) where it will not tip from an upright position, which in general is at some distance from the patient. Often, it requires a person to hold it in the proper orientation, particularly if the patient is fighting treatment. The long run of conduit means  130  results in considerable condensation of medication on the interior walls. Up to about one-half or more of the medication may condense and never enter the patients&#39;s airway;     (c) The optimum CPAP oxygen rate for a patient&#39;s respiration may differ widely from the optimum rate for achieving a desired nebulization rate of medication. An EMT may be required to determine some compromise, with resulting non-optimum treatment of the patient with respect to either or both of total oxygen supplied and nebulized medication supplied to the patient.      
         [0053]     In  FIG. 2A , a PRIOR ART medication dosing system  101  is shown which may be used with a CPAP apparatus. The system includes a nebulizer  140  having a medication jar  142  and cap  144 . The nebulizer outlet  148  is rigidly held in inhalation port  112  of the CPAP mask  110 . Oxygen and/or air from source  102  is fed through fitting  138  and inlet tubing  136  to the inlet port  146  of nebulizer  140 , wherein the liquid medication  160  is so-called “vaporized” or “aerosolized” into an aerosol and delivered to the mask  110  for uptake by the patient. In general practice, the CPAP conduit means  130  is removed during the period of medication delivery, resulting in periods without the necessary oxygenation under pressure. The loss of CPAP oxygen flow may result in under-oxygenation of a patient. As already stated, the method is not effective unless it is possible to maintain the nebulizer  140  in an upright attitude where a major portion of the medication  160  will be nebulized. Furthermore, blockage of the airway because of loss of CPAP pressure will tend to prevent effective contact of medication aerosol with the patient&#39;s lungs.  
         [0054]     In an alternative method, the CPAP mask is simply removed and replaced by a standard nebulizer facemask  152  for medication delivery, as shown in Prior Art  FIG. 3 . The airway pressure is lost during medication delivery.  
         [0055]     In contrast to apparatus and methods of the prior art, the medication delivery device  10  and methods of the present invention, as depicted in  FIGS. 4, 5 ,  6  and  7 , solve various afore-mentioned problems associated with the methods and apparatus of the prior art.  
         [0056]     First, use of the device of the invention permits the patient&#39;s head  150  to be in any position or attitude, without jeopardizing full delivery of the medication aerosol.  
         [0057]     Second, the method of the invention produces co-delivery of the oxygen-containing CPAP gas and aerosol of the medication  160  during both of the inhalation and exhalation periods of a breathing cycle. It is not necessary to shut down the CPAP apparatus  100  for extended periods during medication delivery and/or nebulizer refilling/exchange.  
         [0058]     Third, the pressures and flowrates of CPAP gas and medication delivery gas are separately controllable, making possible control of the medication rate from slow to very rapid.  
         [0059]     Fourth, the device is simple and very lightweight. It takes up little space, whereby three units are generally storable in less than about 0.05 cubic foot. Thus, a number of the devices  10  may be easily placed and used on an emergency vehicle.  
         [0060]     Fifth, the device is primarily intended for use with a CPAP apparatus at positive pressure. If necessary, however, it may also be simply used in combination with a nebulizer face mask  152 , replacing use of a conventional nebulizer  30  which fits directly into the mask, particularly when the patient&#39;s head cannot be lifted to at least a somewhat upright position.  
         [0061]     Sixth, the device and method of the invention are considered to be well within EMT protocol and easily used thereby, thus enabling inclusion in emergency vehicles, even in the absence of a physician or paramedic.  
         [0062]     The apparatus of the invention comprises a medication delivery device  10  for concurrent/simultaneous use with emergency CPAP ventilation of a patient. As shown in  FIG. 4 , a conventional CPAP apparatus with attached medication delivery device  10  of the invention is designated herein as combined CPAP/medication delivery apparatus  50 .  
         [0063]     The medication delivery device  10  comprises a nebulizer  30  shown with a medication container  26  e.g. jar which is removable from nebulizer cap  28  along jar/cap interface  29  for placement of a liquid medication  160  therein. Typically, the container  26  is sealably attached to the cap  28  by screw threads or a compression (snap) fitting, not shown. The nebulizer  30  may be of any design or manufacture useful in medication nebulization, provided that it will assume an upright attitude for full nebulization when freely suspended from a medicinal aerosol delivery tube  20  attached to the first port  16  of Tee fitting  12 . Oxygen and/or air is directed to nebulizer  30  from a gas source  102  through fitting  38  and gas supply tube  36 , to nebulize the medication  160  to an aerosol  162 . The gas source  102  may be the same source which supplies the CPAP unit  100 , or may comprise a different source, e.g. a different oxygen cylinder. The oxygen/air supplied to the nebulizer  30  must be of a higher pressure than the oxygen/air supplied to the CPAP device, to compensate for the pressure drop across the nebulizing nozzle, not shown, within the nebulizer  30 .  
         [0064]     A medicinal aerosol delivery tube  20  has a first end  54  connected to the nebulizer outlet port  34  and a second end  56  connected to one port, preferably a side port  16 , of a three port Tee fitting  12 . Where conventional medical components are used to form a medication delivery device  10  of the invention, it may be necessary to insert a rigid adapter  42  between the gas port outlet  34  of the nebulizer  30  and the first end  54  of the delivery tube  20 , if the sizes of outlet  34  and first end  54  are not compatible.  
         [0065]     The three port Tee fitting  12  has a second port  14  which is connectable to the second end  131 B of second conduit means  130 , for flow of CPAP oxygen  158  therethrough. Third port  18  of Tee fitting  12  is configured to mate with the inhalation port  112  of the CPAP mask  110 . As already indicated, first port  16  of Tee fitting  12  is connectable to the medicinal delivery tube  20 .  
         [0066]     When suspended from the short piece of delivery tube  20 , the nebulizer remains in a vertical attitude for providing a continuous aerosol stream  162  irrespective of the attitude of a patient&#39;s head  150  or upper body. Use of a short delivery tube  20 , such as 8-20 cm., enables the nebulizer  30  to be suspended to one side of a patient&#39;s head and remain in a vertical attitude. With a longer delivery tube, the nebulizer may be suspended to the side of a body support such as a gurney or bed, not shown.  
         [0067]     Continuing in  FIG. 4 , second conduit means  130  of the CPAP apparatus  100  has a first end  131 A connected through outlet  126  to an exemplary diluter  106 . The second end  131 B of the second conduit means  130  is shown connected to the second Tee fitting port  14 . The third Tee fitting port  18  is shown connected to the mask inhalation port  112 , for mixing and simultaneous continuous injection of a pressurized oxygenation gas  158  and an aerosol  162  of medication  160  into a CPAP mask  110 . The mask  110  is configured to maintain a continuous positive pressure in the patient&#39;s airway.  
         [0068]     Turning now to  FIG. 5 , individual elements of an exemplary medication delivery device  10  of the invention are shown in an exploded view. These elements include a Tee fitting  12  with first port  16 , second port  14  and third port  18 . Ports  14  and  18  are shown as having common centerline  46 , while second port  14  intercepts centerline  46  at a preferred angle  48  of 90 degrees. Another angle  48  such as e.g. 30 degrees or 45 degrees may be used. In  FIG. 5 , the second port  14  of the Tee fitting  12  is typically a male port which fits into second conduit means  130 , and the third port of Tee fitting  12  is typically a female port which accepts the male inhalation port  112  of the mask  110 . The Tee fitting  12  may be formed to include an internal orifice, not shown, of reduced diameter for increasing the velocity of CPAP gas  158  (decreasing the pressure thereof) past the entering nebulized aerosol stream  162 , thus drawing the aerosol into the CPAP gas and enhancing mixing.  
         [0069]     In  FIG. 5 , a medicinal delivery tube  20  is shown with an outlet end  24  connectable to port  16  of the Tee fitting  12  by direct connection. Aerosol delivery tube  20  has sufficient flexibility to readily form a bend to a vertical orientation within a small length of tube  20 , in order to make the nebulizer  30  orientation independent of the patient&#39;s position. Thus, for example, a readily available corrugated plastic tubular material of nominal 1-2 cm. ID will bend at least 180 degrees within a length of about 10-20 cm. under the suspended weight of a conventional small nebulizer  30  used by emergency teams. However, tubing which will bend through at least 120 degrees in the same length may also be used. A conventional nebulizer in widespread use weighs about one ounce (28 g). Thus, the best tube material available will readily support a nebulizer  30  in a vertical position, regardless of the attitude of a patient&#39;s head. The delivery tube  20  is typically formed of a short length of a flexible corrugated plastic tubing of a smaller diameter than the diameter of the second conduit means  130 . Preferably, the aerosol delivery tube  20  has a diameter about one-half that of the CPAP oxygen supply tube  130 . An example of a tubing which works well as a delivery tube  20  is a nominal ½ inch (1.27 cm.) outside diameter corrugated tubing formed of polyethylene, available from Carodyne, which has a place of business in Indianapolis, Ind. The medication delivery apparatus of the invention, including nebulizer  30 , adapter  22 , delivery tube  20  and Tee fitting  12  may weigh as little as about 2 ounces (56 grams) or less.  
         [0070]     As shown, the tube inlet end  22  of the delivery tube  20  is attachable to the gas port outlet  34  of nebulizer  30 , either through adapter  42 , or by direct connection to the outlet  34 .  
         [0071]     Nebulizer  30  may be of any construction useful in the medical field. For use in emergency vehicles and the like, where space is limited, it is preferable to stock as few types of equipment as possible; so a single type of nebulizer is preferably used to satisfy all or most of the needs. For use in this invention, it is required that the nebulizer be constructed for suspension from a medication delivery tube  20  in an orientation which permits the desired maximum continuous nebulization of medication  160 . Refilling or exchange of a nebulizer  30  is readily accomplished during CPAP operation. Exchange of a nebulizer is possible in a short time, i.e. seconds. The inlet gas port  32  of nebulizer  30  is connectable to a source of oxygen-containing gas by an intervening gas supply tube  36 . The pressure and flow rate of oxygen/air are controlled by means known in the art to provide the desired aerosolization rate. Such pressure and flow controlling means may be further incorporated into a BiPAP/CPAP machine, so that the CPAP gas  158  and nebulizer gas  162  have independently controlled pressures and flow rates. Lightweight plastic nebulizers useful in the present invention are commercially available, and together with connected tubing are intended to be disposable after use by a patient.  
         [0072]     As shown in  FIG. 6 , a Tee fitting  12  may be connected in an alternate configuration where the aerosol  162  is introduced into a port  14  or  18  other than the side port  16  of the Tee fitting. The 3-port fitting  12  may also comprise a Y fitting or in fact have ports  14 ,  16  and  18  at any angle  48  to each other, provided ready connection/disconnection and rapid delivery of the aerosol are achieved.  
         [0073]     Turning now to  FIG. 7 , a secondary use of the medication dosing apparatus  10  of the invention is illustrated. Simple supply of a medicinal aerosol  162  and oxygen to a patient may be conducted despite a prone position of a patient&#39;s head  150 . As shown in this figure, a non-CPAP (non-pressurized) mask  152  has an inlet port  164  and vents  156  through which exhalate  119  is vented. Despite the generally horizontal orientation of the inlet port  164 , the nebulizer  30  is maintained in a non-spilling vertical orientation for efficient nebulization of liquid medication  160  to an aerosol by a stream of gas, e.g. oxygen or air from source  102 .  
         [0074]     As already indicated, methods of the invention avoid problems in administering medication aerosols in emergency situations, and result in added comfort to the patient, avoidance of endotracheal intubation, enhanced control of nebulization over a wide range of rates, generally higher nebulization rates, and decreased work load for the attending EMT&#39;s.  
         [0075]     The present invention has been described in specific embodiments intended in all respects to be illustrative rather than limiting in natue. It is to be understood that the invention defined by the appended claims is not to be limited by specific details set forth in the above description and that alternative embodiments will become apparent to those of ordinary skill in the art to which the invention pertains without departing from the spirit and scope thereof.