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Wang HE, Levy M, Cone DC. The National Association of EMS Physicians Compendium of Airway Management Position Statements and Resource Documents. PREHOSP EMERG CARE 2022; 26:1-2. [PMID: 35001827 DOI: 10.1080/10903127.2021.1988776] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Henry E Wang
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio (HEW); Anchorage Areawide EMS Anchorage AK, University of Alaska Anchorage College of Health, Washington Wyoming Alaska Montana Idaho School of Medical Education, Anchorage, Alaska (ML); Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut (DCC). Revision received September 28, 2021; accepted for publication September 28, 2021
| | - Michael Levy
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio (HEW); Anchorage Areawide EMS Anchorage AK, University of Alaska Anchorage College of Health, Washington Wyoming Alaska Montana Idaho School of Medical Education, Anchorage, Alaska (ML); Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut (DCC). Revision received September 28, 2021; accepted for publication September 28, 2021
| | - David C Cone
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio (HEW); Anchorage Areawide EMS Anchorage AK, University of Alaska Anchorage College of Health, Washington Wyoming Alaska Montana Idaho School of Medical Education, Anchorage, Alaska (ML); Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut (DCC). Revision received September 28, 2021; accepted for publication September 28, 2021
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Sellmann T, Meyer J. Nichtinvasive Ventilation im Notarzt- und Rettungsdienst. Notf Rett Med 2017. [DOI: 10.1007/s10049-017-0372-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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A pilot, prospective, randomized trial of video versus direct laryngoscopy for paramedic endotracheal intubation. Resuscitation 2017; 114:121-126. [DOI: 10.1016/j.resuscitation.2017.03.022] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Revised: 03/14/2017] [Accepted: 03/15/2017] [Indexed: 12/13/2022]
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Pandor A, Thokala P, Goodacre S, Poku E, Stevens JW, Ren S, Cantrell A, Perkins GD, Ward M, Penn-Ashman J. Pre-hospital non-invasive ventilation for acute respiratory failure: a systematic review and cost-effectiveness evaluation. Health Technol Assess 2016; 19:v-vi, 1-102. [PMID: 26102313 DOI: 10.3310/hta19420] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Non-invasive ventilation (NIV), in the form of continuous positive airway pressure (CPAP) or bilevel inspiratory positive airway pressure (BiPAP), is used in hospital to treat patients with acute respiratory failure. Pre-hospital NIV may be more effective than in-hospital NIV but requires additional ambulance service resources. OBJECTIVES We aimed to determine the clinical effectiveness and cost-effectiveness of pre-hospital NIV compared with usual care for adults presenting to the emergency services with acute respiratory failure and to identify priorities for future research. DATA SOURCES Fourteen electronic databases and research registers (including MEDLINE In-Process & Other Non-Indexed Citations, MEDLINE, EMBASE, and Cumulative Index to Nursing and Allied Health Literature) were searched from inception to August 2013, supplemented by hand-searching reference lists and contacting experts in the field. REVIEW METHODS We included all randomised or quasi-randomised controlled trials of pre-hospital NIV in patients with acute respiratory failure. Methodological quality was assessed according to established criteria. An aggregate data network meta-analysis (NMA) of mortality and intubation was used to jointly estimate intervention effects relative to usual care. A NMA, using individual patient-level data (IPD) and aggregate data where IPD were not available, was carried out to assess whether or not covariates were treatment effect modifiers. A de novo economic model was developed to explore the costs and health outcomes when pre-hospital NIV (specifically CPAP provided by paramedics) and standard care (in-hospital NIV) were applied to a hypothetical cohort of patients with acute respiratory failure. RESULTS The literature searches identified 2284 citations. Of the 10 studies that met the inclusion criteria, eight were randomised controlled trials and two were quasi-randomised trials (six CPAP; four BiPAP; sample sizes 23-207 participants). IPD were available from seven trials (650 patients). The aggregate data NMA suggested that CPAP was the most effective treatment in terms of mortality (probability = 0.989) and intubation rate (probability = 0.639), and reduced both mortality [odds ratio (OR) 0.41, 95% credible interval (CrI) 0.20 to 0.77] and intubation rate (OR 0.32, 95% CrI 0.17 to 0.62) compared with standard care. The effect of BiPAP on mortality (OR 1.94, 95% CrI 0.65 to 6.14) and intubation rate (OR 0.40, 95% CrI 0.14 to 1.16) compared with standard care was uncertain. The combined IPD and aggregate data NMA suggested that sex was a statistically significant treatment effect modifier for mortality. The economic analysis showed that pre-hospital CPAP was more effective and more expensive than standard care, with an incremental cost-effectiveness ratio of £20,514 per quality-adjusted life-year (QALY) and a 49.5% probability of being cost-effective at the £20,000-per-QALY threshold. Variation in the incidence of eligible patients had a marked impact on cost-effectiveness and the expected value of sample information for a future randomised trial. LIMITATIONS The meta-analysis lacked power to detect potentially important differences in outcome (particularly for BiPAP), the intervention was not always compared with the best alternative care (in-hospital NIV) in the primary studies and findings may not be generalisable. CONCLUSIONS Pre-hospital CPAP can reduce mortality and intubation rates, but cost-effectiveness is uncertain and the value of further randomised evaluation depends on the incidence of suitable patients. A feasibility study is required to determine if a large pragmatic trial of clinical effectiveness and cost-effectiveness is appropriate. STUDY REGISTRATION The study is registered as PROSPERO CRD42012002933. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Abdullah Pandor
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Praveen Thokala
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Edith Poku
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - John W Stevens
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Shijie Ren
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Anna Cantrell
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Matt Ward
- West Midlands Ambulance Service NHS Foundation Trust, West Midlands, UK
| | - Jerry Penn-Ashman
- West Midlands Ambulance Service NHS Foundation Trust, West Midlands, UK
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Tennyson J. Controversies in the Care of the Acute Asthmatic in the Prehospital and Emergency Department Environments. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2015. [DOI: 10.1007/s40138-015-0082-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Thokala P, Goodacre S, Ward M, Penn-Ashman J, Perkins GD. Cost-effectiveness of Out-of-Hospital Continuous Positive Airway Pressure for Acute Respiratory Failure. Ann Emerg Med 2015; 65:556-563.e6. [PMID: 25737210 PMCID: PMC4414542 DOI: 10.1016/j.annemergmed.2014.12.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Revised: 12/04/2014] [Accepted: 12/12/2014] [Indexed: 01/15/2023]
Abstract
STUDY OBJECTIVE We determine the cost-effectiveness of out-of-hospital continuous positive airway pressure (CPAP) compared with standard care for adults presenting to emergency medical services with acute respiratory failure. METHODS We developed an economic model using a United Kingdom health care system perspective to compare the costs and health outcomes of out-of-hospital CPAP to standard care (inhospital noninvasive ventilation) when applied to a hypothetical cohort of patients with acute respiratory failure. The model assigned each patient a probability of intubation or death, depending on the patient's characteristics and whether he or she had out-of-hospital CPAP or standard care. The patients who survived accrued lifetime quality-adjusted life-years (QALYs) and health care costs according to their age and sex. Costs were accrued through intervention and hospital treatment costs, which depended on patient outcomes. All results were converted into US dollars, using the Organisation for Economic Co-operation and Development purchasing power parities rates. RESULTS Out-of-hospital CPAP was more effective than standard care but was also more expensive, with an incremental cost-effectiveness ratio of £20,514 per QALY ($29,720/QALY) and a 49.5% probability of being cost-effective at the £20,000 per QALY ($29,000/QALY) threshold. The probability of out-of-hospital CPAP's being cost-effective at the £20,000 per QALY ($29,000/QALY) threshold depended on the incidence of eligible patients and varied from 35.4% when a low estimate of incidence was used to 93.8% with a high estimate. Variation in the incidence of eligible patients also had a marked influence on the expected value of sample information for a future randomized trial. CONCLUSION The cost-effectiveness of out-of-hospital CPAP is uncertain. The incidence of patients eligible for out-of-hospital CPAP appears to be the key determinant of cost-effectiveness.
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Affiliation(s)
- Praveen Thokala
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom.
| | - Steve Goodacre
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Matt Ward
- West Midlands Ambulance Service National Health Service Foundation Trust, Brierley Hill, West Midlands, United Kingdom
| | - Jerry Penn-Ashman
- West Midlands Ambulance Service National Health Service Foundation Trust, Brierley Hill, West Midlands, United Kingdom
| | - Gavin D Perkins
- Warwick Medical School and Heart of England National Health Service Foundation Trust, Coventry, United Kingdom
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Goodacre S, Stevens JW, Pandor A, Poku E, Ren S, Cantrell A, Bounes V, Mas A, Payen D, Petrie D, Roessler MS, Weitz G, Ducros L, Plaisance P. Prehospital noninvasive ventilation for acute respiratory failure: systematic review, network meta-analysis, and individual patient data meta-analysis. Acad Emerg Med 2014; 21:960-70. [PMID: 25269576 DOI: 10.1111/acem.12466] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2014] [Revised: 05/08/2014] [Accepted: 05/13/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVES This meta-analysis aimed to determine the effectiveness of prehospital continuous positive airway pressure (CPAP) or bilevel inspiratory positive airway pressure (BiPAP) in acute respiratory failure. METHODS Fourteen electronic databases and research registers were searched from inception to August 2013. Randomized or quasi-randomized controlled trials that reported mortality or intubation rate for prehospital CPAP or BiPAP were selected and compared to a relevant comparator in patients with acute respiratory failure. An aggregate data network meta-analysis was used to jointly estimate intervention effects relative to standard care. A network meta-analysis using a mixture of individual patient-level data and aggregate data was carried out to assess potential treatment effect modifiers. RESULTS Eight randomized and two quasi-randomized controlled trials (six CPAP, four BiPAP, sample sizes 23 to 207) were identified. The aggregate data network meta-analysis suggested that CPAP was the most effective treatment in terms of mortality (probability = 0.989) and intubation rate (probability = 0.639) and reduced both mortality (odds ratio [OR] = 0.41; 95% credible interval [CrI] = 0.20 to 0.77) and intubation rate (OR = 0.32; 95% CrI = 0.17 to 0.62), compared to standard care. The effect of BiPAP on mortality (OR = 1.94; 95% CrI = 0.65 to 6.14) and intubation rate (OR = 0.40; 95% CrI = 0.14 to 1.16) was uncertain. The network meta-analysis using individual patient-level data and aggregate data suggested that sex was a modifier of the effect of treatment on mortality. CONCLUSIONS Prehospital CPAP can reduce mortality and intubation rates compared to standard care, while the effectiveness of prehospital BiPAP is uncertain.
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Affiliation(s)
- Steve Goodacre
- The School of Health and Related Research (ScHARR) University of Sheffield Sheffield UK
| | - John W. Stevens
- The School of Health and Related Research (ScHARR) University of Sheffield Sheffield UK
| | - Abdullah Pandor
- The School of Health and Related Research (ScHARR) University of Sheffield Sheffield UK
| | - Edith Poku
- The School of Health and Related Research (ScHARR) University of Sheffield Sheffield UK
| | - Shijie Ren
- The School of Health and Related Research (ScHARR) University of Sheffield Sheffield UK
| | - Anna Cantrell
- The School of Health and Related Research (ScHARR) University of Sheffield Sheffield UK
| | - Vincent Bounes
- The Department of Emergency Medicine Toulouse University Hospital Toulouse France
| | - Arantxa Mas
- The Intensive Care Department Hospital de Sant Joan Despí Moisès Broggi Barcelona Spain
| | - Didier Payen
- The Department of Anaesthesiology and Critical Care Lariboisière Hospital Paris France
| | - David Petrie
- The Department of Emergency Medicine Dalhousie University Nova Scotia Canada
| | - Markus Soeren Roessler
- The Department of Anaesthesiology Emergency and Intensive Care Medicine Georg‐August‐University Goettingen Germany
| | - Gunther Weitz
- The University Hospital of Schleswig‐Holstein Lübeck Germany
| | - Laurent Ducros
- The Department of Anaesthesiology and Critical Care Lariboisière Hospital Paris France
| | - Patrick Plaisance
- The Department of Emergency Medicine Lariboisière University Hospital Paris France
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Mal S, McLeod S, Iansavichene A, Dukelow A, Lewell M. Effect of out-of-hospital noninvasive positive-pressure support ventilation in adult patients with severe respiratory distress: a systematic review and meta-analysis. Ann Emerg Med 2013; 63:600-607.e1. [PMID: 24342819 DOI: 10.1016/j.annemergmed.2013.11.013] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Revised: 11/05/2013] [Accepted: 11/15/2013] [Indexed: 11/30/2022]
Abstract
STUDY OBJECTIVE Noninvasive positive-pressure ventilation (NIPPV) is increasingly being used by emergency medical services (EMS) for treatment of patients in respiratory distress. The primary objective of this systematic review is to determine whether out-of-hospital NIPPV for treatment of adults with severe respiratory distress reduces inhospital mortality compared with "standard" therapy. Secondary objectives are to examine the need for invasive ventilation, hospital and ICU length of stay, and complications. METHODS Electronic searches of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing and Allied Health Literature were conducted and reference lists of relevant articles hand searched. Randomized controlled trials comparing out-of-hospital NIPPV with standard therapy in adults (aged ≥16 years) with severe respiratory distress published in English were included. Two reviewers independently screened abstracts, assessed quality of the studies, and extracted data. Data were pooled with random-effects models and reported as risk ratios (RRs) with 95% confidence intervals (CIs) and number needed to treat (NNT). RESULTS Seven randomized controlled trials were included, with a combined total of 632 patients; 313 in the standard therapy group and 319 in the NIPPV group. In patients treated with NIPPV, the pooled estimate showed a reduction in both inhospital mortality (RR 0.58; 95% CI 0.35 to 0.95; NNT=18) and need for invasive ventilation (RR 0.37; 95% CI 0.24 to 0.58; NNT=8). There was no difference in ICU or hospital length of stay. CONCLUSION Out-of-hospital administration of NIPPV appears to be an effective therapy for adult patients with severe respiratory distress.
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Affiliation(s)
- Sameer Mal
- Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada; London Health Sciences Centre, London, Ontario, Canada.
| | - Shelley McLeod
- Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada; London Health Sciences Centre, London, Ontario, Canada
| | | | - Adam Dukelow
- Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada; London Health Sciences Centre, London, Ontario, Canada
| | - Michael Lewell
- Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada; London Health Sciences Centre, London, Ontario, Canada
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Le Cong M, Robertson A. A 3-year retrospective audit of the use of noninvasive positive pressure ventilation via the Oxylog 3000 transport ventilator during air medical retrievals. Air Med J 2013; 32:126-128. [PMID: 23632220 DOI: 10.1016/j.amj.2012.10.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2011] [Revised: 07/07/2012] [Accepted: 10/21/2012] [Indexed: 06/02/2023]
Abstract
INTRODUCTION The purpose of this study was to describe the safety profile of noninvasive positive pressure ventilation (NIPPV) using the Oxylog 3000 transport ventilator (Drager Medical, Lübeck, Germany) by air medical retrieval teams from the Queensland Section of the Royal Flying Doctor Service of Australia. METHODS Over a 3-year period, patients identified in clinical transport records to have NIPPV via the Oxylog 3000 transport ventilator during air medical transfer were systematically reviewed on the clinical indication and adverse effects. RESULTS A total of 29 patients were identified to have had treatment with NIPPV during air medical retrieval. Three patients suffered serious adverse effects of cardiorespiratory arrest during treatment. The main reported adverse event was intolerance of the facemask. There were no documented episodes of vomiting or hypotension. CONCLUSION The use of NIPPV via the Oxylog 3000 transport ventilator during air medical retrieval requires careful patient selection. The application and management do not differ from standard hospital-based practice.
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Affiliation(s)
- Minh Le Cong
- Royal Flying Doctor Service, Cairns, Queensland, Australia.
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Williams TA, Finn J, Celenza A, Teng TH, Jacobs IG. Paramedic identification of acute pulmonary edema in a metropolitan ambulance service. PREHOSP EMERG CARE 2013; 17:339-47. [PMID: 23484502 DOI: 10.3109/10903127.2013.773114] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Acute pulmonary edema (APE) is a common cause of acute dyspnea. In the prehospital setting, it is often difficult to differentiate APE from other causes of shortness of breath (SOB). Radiography and echocardiography aid in the identification of APE but are often not available. There is little information on how accurately ambulance paramedics identify patients with APE. Objectives. This study aimed to 1) describe the prehospital clinical presentation and management of patients with a clinical diagnosis of APE and 2) compare the accuracy of coding of APE by paramedics against the emergency department (ED) medical discharge diagnosis. METHODS This study included a retrospective cohort of all patients who had episodes identified as APE by ambulance paramedics and were transported to a metropolitan hospital ED in 2011. Two databases were used: an ambulance database and the Emergency Department Information System. The ED medical discharge diagnosis (using International Statistical Classification of Diseases and Related Problems, 10th Revision, Australian Modification [ICD-10-AM] codes) was used as the comparator with paramedic-assigned problem codes for APE. The outcomes for the study were the positive predictive value, i.e., the proportion of patients identified as having APE in the ambulance database who also had an ED discharge diagnosis of APE, and the sensitivity of paramedic identification of APE, i.e., the proportion of patients with an ED discharge diagnosis of APE that were correctly identified as APE by the ambulance paramedics. RESULTS Four hundred ninety-five patients were transported to an ED with APE identified by the paramedics as the primary problem code. Shortness of breath, crepitations, high systolic blood pressure, and chest pain were the most common presenting signs and symptoms. Pink frothy sputum was rare (3% of patient episodes of APE). One hundred eighty-six patients received an ED discharge diagnosis of APE, i.e., a positive predictive value of 41%. Of 631 ED presentations with APE, paramedics identified 186, i.e., a sensitivity of 29%. CONCLUSION Acute pulmonary edema is difficult to identify in the prehospital setting because of the variability in the signs and symptoms associated with this condition. Improved identification of APE is essential in the initiation of appropriate and timely care. Ambulance paramedics need to be aware of such variability when considering patients who may be suffering from APE. Key words: pulmonary edema; acute pulmonary edema; emergency medical services; ambulance; paramedics.
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Affiliation(s)
- Teresa A Williams
- The University of Western Australia, Emergency Medicine , 35 Stirling Highway, Crawley, 6009 Australia.
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Williams TA, Finn J, Perkins GD, Jacobs IG. Prehospital continuous positive airway pressure for acute respiratory failure: a systematic review and meta-analysis. PREHOSP EMERG CARE 2013; 17:261-73. [PMID: 23373591 DOI: 10.3109/10903127.2012.749967] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Acute respiratory failure (ARF) is a common problem encountered by emergency medical services and is associated with significant morbidity, mortality, and health care costs. Continuous positive airway pressure (CPAP) is an integral part of the hospital treatment of acute ARF, predominantly because of congestive heart failure. Intuitively, better patient outcomes may be achieved when CPAP is applied early in the prehospital setting, but there are few outcome studies to validate its use in this setting. OBJECTIVE This systematic review and meta-analysis aimed to examine the effectiveness of CPAP in the prehospital setting for patients with ARF. METHODS A literature review of bibliographic databases and secondary sources was conducted and potential papers were assessed by two independent reviewers. Included studies were those that compared CPAP therapy (and usual care) with no CPAP for ARF in the prehospital setting. Studies of other methods of noninvasive ventilation were not included. Methodologic quality was assessed using guidelines from the Cochrane Collaboration. Outcomes included the number of intubations, mortality, physiologic parameters, and dyspnea score. Forrest plots were constructed to estimate the pooled effect of CPAP on outcomes. RESULTS Five studies (1,002 patients) met the selection criteria--three randomized controlled trials (RCTs), a nonrandomized comparative study, and a retrospective comparative study using chart review. Forty-seven percent of the patients were allocated to the CPAP group. Baseline characteristics were similar between groups. The pooled estimates demonstrated significantly fewer intubations (odds ratio [OR] 0.31; 95% confidence interval [CI] 0.19-0.51) and lower mortality (OR 0.41; 95% CI 0.19-0.87) in the CPAP group. CONCLUSION The studies included in this review showed a reduction in the number of intubations and mortality in patients with ARF who received CPAP in the prehospital setting. The results may not be applicable to other health care contexts because of the inherent differences in the organization and staffing of the EMS systems. Information from large RCTs on the efficacy of CPAP initiated early in the prehospital setting is critical to establishing the evidence base underpinning this therapy before ambulance services incorporate CPAP as routine clinical practice.
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Rose L. Management of critically ill patients receiving noninvasive and invasive mechanical ventilation in the emergency department. Open Access Emerg Med 2012; 4:5-15. [PMID: 27147858 PMCID: PMC4753973 DOI: 10.2147/oaem.s25048] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Patients requiring noninvasive and invasive ventilation frequently present to emergency departments, and may remain for prolonged periods due to constrained critical care services. Emergency clinicians often do not receive the same education on management of mechanical ventilation or have similar exposure to these patients as do their critical care colleagues. The aim of this review was to synthesize the evidence on management of patients requiring noninvasive and invasive ventilation in the emergency department including indications, clinical applications, monitoring priorities, and potential complications. Noninvasive ventilation is recommended for patients with acute exacerbation of chronic obstructive pulmonary disease or cardiogenic pulmonary edema. Less evidence supports its use in asthma and other causes of acute respiratory failure. Use of noninvasive ventilation in the prehospital setting is relatively new, and some evidence suggests benefit. Monitoring priorities for noninvasive ventilation include response to treatment, respiratory and hemodynamic stability, noninvasive ventilation tolerance, detection of noninvasive ventilation failure, and identification of air leaks around the interface. Application of injurious ventilation increases patient morbidity and mortality. Lung-protective ventilation with low tidal volumes based on determination of predicted body weight and control of plateau pressure has been shown to reduce mortality in patients with acute respiratory distress syndrome, and some evidence exists to suggest this strategy should be used in patients without lung injury. Monitoring of the invasively ventilated patient should focus on assessing response to mechanical ventilation and other interventions, and avoiding complications, such as ventilator-associated pneumonia. Several key aspects of management of noninvasive and invasively ventilated patients are discussed, with a particular emphasis on initiation and ongoing monitoring priorities focused on maintaining patient safety and improving patient outcomes.
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Affiliation(s)
- Louise Rose
- Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
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Bledsoe BE, Anderson E, Hodnick R, Johnson L, Johnson S, Dievendorf E. Low-fractional oxygen concentration continuous positive airway pressure is effective in the prehospital setting. PREHOSP EMERG CARE 2011; 16:217-21. [PMID: 22191942 DOI: 10.3109/10903127.2011.640765] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The objective of this study was to determine the effects of low-fractional concentration of inspired oxygen (FiO(2)) continuous positive airway pressure (CPAP) in prehospital noninvasive ventilation (NIV). With increasing concerns about the detrimental effects of hyperoxia, we sought to determine whether CPAP using a low FiO(2) (28%-30%) was effective in the prehospital setting. METHODS The study was a six-month prospective, nonblinded observational study conducted in a large, busy urban emergency medical services (EMS) system (Las Vegas, NV). RESULTS A total of 340 patients participated in the study. Most patients presented with symptoms consistent with a diagnosis of congestive heart failure/acute pulmonary edema (47.4%), followed by chronic obstructive pulmonary disease (COPD) (40.9%), asthma (22.7%), and pneumonia (15.9%). Improvements were seen in respiratory rate (p = 0.00) and oxygen saturation (p = 0.00). The overall CPAP discontinuation rate was 16.5%. The most common reason for CPAP discontinuation was anxiety/claustrophobia. The total number of patients requiring prehospital intubation was 5.6%. Subjective paramedic assessment of patient status at hospital delivery found that 71.5% of patients' conditions were improved, 15.1% remained unchanged, and 13.4% were worse. CONCLUSIONS CPAP using a low FiO(2) (28%-30%) was highly effective in the treatment of commonly encountered prehospital respiratory emergencies.
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Affiliation(s)
- Bryan E Bledsoe
- Department of Emergency Medicine, University of Nevada School of Medicine, Las Vegas, NV 89106, USA.
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