Adult Patients with Respiratory Distress: Current Evidence-based Recommendations for Prehospital Care

Abstract

Introduction We developed evidence-based recommendations for prehospital evaluation and treatment of adult patients with respiratory distress. These recommendations are compared with current protocols used by the 33 local emergency medical services agencies (LEMSA) in California. Methods We performed a review of the evidence in the prehospital treatment of adult patients with respiratory distress. The quality of evidence was rated and used to form guidelines. We then compared the respiratory distress protocols of each of the 33 LEMSAs for consistency with these recommendations. Results PICO (population/problem, intervention, control group, outcome) questions investigated were treatment with oxygen, albuterol, ipratropium, steroids, nitroglycerin, furosemide, and non-invasive ventilation. Literature review revealed that oxygen titration to no more than 94–96% for most acutely ill medical patients and to 88–92% in patients with acute chronic obstructive pulmonary disease (COPD) exacerbation is associated with decreased mortality. In patients with bronchospastic disease, the data shows improved symptoms and peak flow rates after the administration of albuterol. There is limited data regarding prehospital use of ipratropium, and the benefit is less clear. The literature supports the use of systemic steroids in those with asthma and COPD to improve symptoms and decrease hospital admissions. There is weak evidence to support the use of nitrates in critically ill, hypertensive patients with acute pulmonary edema (APE) and moderate evidence that furosemide may be harmful if administered prehospital to patients with suspected APE. Non-invasive positive pressure ventilation (NIPPV) is shown in the literature to be safe and effective in the treatment of respiratory distress due to acute pulmonary edema, bronchospasm, and other conditions. It decreases both mortality and the need for intubation. Albuterol, nitroglycerin, and NIPPV were found in the protocols of every LEMSA. Ipratropium, furosemide, and oxygen titration were found in a proportion of the protocols, and steroids were not prescribed in any LEMSA protocol. Conclusion Prehospital treatment of adult patients with respiratory distress varies widely across California. We present evidence-based recommendations for the prehospital treatment of undifferentiated adult patients with respiratory distress that will assist with standardizing management and may be useful for EMS medical directors when creating and revising protocols.

Patients' lived experiences of breathlessness prior to prehospital care – A phenomenological study

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This study is a part of a larger prehospital research project exploring patients with breathlessness who are in need of prehospital care. As breathlessness (also known as dyspnoea) is one of the most common reasons why patients are in need of prehospital care (Hodroge et al, 2020;Kelly et al, 2016), this phenomenological study is focused on patients' experiences of suffering from breathlessness to such an extent that prehospital care is required. In this study, the prehospital situation includes the event prior to patients' contact with the emergency number (112) and their time awaiting help from the ACs while experiencing breathlessness.

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Protocol for assessing mortality reduction with the early use of noninvasive ventilation in prehospital emergency services: A multicentre, observational cohort study in Madrid, Spain

“…Our results will also show whether the most frequently used NIV, according to the literature, is BiPAP or NIV with PS. 9,20,23 However, the innovative aspect of our study resides in contributing to the evidence of NIV use in the prehospital EMS setting. While the mortality reduction among patients with ACOPD and APE receiving in-patient NIV is well documented, 10,11,21 findings from international studies focused on prehospital use of NIV remain inconsistent.…”

2021 Guideline for the Management of COPD Exacerbations: Emergency Medicine Association of Turkey (EMAT) / Turkish Thoracic Society (TTS) Clinical Practice Guideline Task Force

“…[ 26 ] In contrast, national and local guidelines in the USA recommend CPAP or BiPAP for patients with severe respiratory distress and bronchospasm. [ 27 28 ]…”

“…Although there are limited data on the prehospital settings, the administration of ipratropium bromide may be considered for patients with suspected bronchospasm. [ 28 ] Salbutamol is administered with a 5 mg nebulizer (or six puffs of MDI) and can be repeated without interruption if the patient's respiratory distress persists. Ipratropium should be administered along with salbutamol for up to three doses.…”

“…[ 30 ] However, several guidelines recommend the use of systemic corticosteroid therapy for COPD exacerbations cases in the prehospital setting. [ 27 28 ]…”