The Journal of Emergency Medicine

2013

DOI: 10.1016/j.jemermed.2013.01.044

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Assessment of the Addition of Prehospital Continuous Positive Airway Pressure (CPAP) to an Urban Emergency Medical Services (EMS) System in Persons with Severe Respiratory Distress

Steve A. Aguilar

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,

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,

Edward M. Castillo

³

et al.

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Assessment Of Clinical Effectiveness5

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Cited by 24 publications

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“…Non-randomised observational studies with a control group Eight studies 60,[64][65][66][67]72,74,77 described the use of pre-hospital NIV in patients with acute respiratory failure. A summary of the studies is presented in Table 13.…”

Section: Assessment Of Clinical Effectivenessmentioning

confidence: 99%

“…Studies were published between 2005 and 2013, and were undertaken in France, 65 Italy, 72 the Netherlands 77 and the USA. 60,64,66,67,74 Three studies 64,72,74 collected data prospectively, while the remaining studies used a retrospective study design. 60,[65][66][67]77 While all studies included patients with acute respiratory distress there was wide variation in terms of underlying conditions resulting in respiratory failure.…”

Section: Assessment Of Clinical Effectivenessmentioning

confidence: 99%

“…60,[65][66][67]77 While all studies included patients with acute respiratory distress there was wide variation in terms of underlying conditions resulting in respiratory failure. Moreover, in two studies, 60,66 patients with acute decompensated heart failure and chronic heart failure were also eligible for inclusion. These conditions may be difficult to distinguish objectively from ACPO in the pre-hospital setting.…”

Section: Assessment Of Clinical Effectivenessmentioning

confidence: 99%

“…The sample sizes of the studies ranged from 42 patients 65 to 467 patients, 64 with the mean age of participants ranging from 68.9 years 65 to 77.7 years 72 (no details of mean age were provided in three studies). 60,66,77 With the exception of one study 65 (which provided limited data), all studies used CPAP as the mode of NIV in the intervention group. Although two studies 64,66 did not provide details relating to the CPAP interface or pressure support level, four studies used a face mask 60,67,74,77 and one used a helmet 72 as the interface of choice for the administration of CPAP.…”

Section: Assessment Of Clinical Effectivenessmentioning

confidence: 99%

“…60,66,77 With the exception of one study 65 (which provided limited data), all studies used CPAP as the mode of NIV in the intervention group. Although two studies 64,66 did not provide details relating to the CPAP interface or pressure support level, four studies used a face mask 60,67,74,77 and one used a helmet 72 as the interface of choice for the administration of CPAP. NIV was administered by paramedics in four studies 60,67,74,77 and by an ambulance nurse in one study.…”

Section: Assessment Of Clinical Effectivenessmentioning

confidence: 99%

See 4 more Smart Citations

Pre-hospital non-invasive ventilation for acute respiratory failure: a systematic review and cost-effectiveness evaluation

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,

²

,

³

et al. 2015

Health Technol Assess

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BackgroundNon-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.ObjectivesWe 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 sourcesFourteen 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 methodsWe 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.ResultsThe 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.LimitationsThe 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.ConclusionsPre-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 registrationThe study is registered as PROSPERO CRD42012002933.FundingThe National Institute for Health Research Health Technology Assessment programme.

“…Non-randomised observational studies with a control group Eight studies 60,[64][65][66][67]72,74,77 described the use of pre-hospital NIV in patients with acute respiratory failure. A summary of the studies is presented in Table 13.…”

Section: Assessment Of Clinical Effectivenessmentioning

confidence: 99%

“…Studies were published between 2005 and 2013, and were undertaken in France, 65 Italy, 72 the Netherlands 77 and the USA. 60,64,66,67,74 Three studies 64,72,74 collected data prospectively, while the remaining studies used a retrospective study design. 60,[65][66][67]77 While all studies included patients with acute respiratory distress there was wide variation in terms of underlying conditions resulting in respiratory failure.…”

Section: Assessment Of Clinical Effectivenessmentioning

confidence: 99%

“…60,[65][66][67]77 While all studies included patients with acute respiratory distress there was wide variation in terms of underlying conditions resulting in respiratory failure. Moreover, in two studies, 60,66 patients with acute decompensated heart failure and chronic heart failure were also eligible for inclusion. These conditions may be difficult to distinguish objectively from ACPO in the pre-hospital setting.…”

Section: Assessment Of Clinical Effectivenessmentioning

confidence: 99%

“…The sample sizes of the studies ranged from 42 patients 65 to 467 patients, 64 with the mean age of participants ranging from 68.9 years 65 to 77.7 years 72 (no details of mean age were provided in three studies). 60,66,77 With the exception of one study 65 (which provided limited data), all studies used CPAP as the mode of NIV in the intervention group. Although two studies 64,66 did not provide details relating to the CPAP interface or pressure support level, four studies used a face mask 60,67,74,77 and one used a helmet 72 as the interface of choice for the administration of CPAP.…”

Section: Assessment Of Clinical Effectivenessmentioning

confidence: 99%

“…60,66,77 With the exception of one study 65 (which provided limited data), all studies used CPAP as the mode of NIV in the intervention group. Although two studies 64,66 did not provide details relating to the CPAP interface or pressure support level, four studies used a face mask 60,67,74,77 and one used a helmet 72 as the interface of choice for the administration of CPAP. NIV was administered by paramedics in four studies 60,67,74,77 and by an ambulance nurse in one study.…”

Section: Assessment Of Clinical Effectivenessmentioning

confidence: 99%

See 3 more Smart Citations

Pre-hospital non-invasive ventilation for acute respiratory failure: a systematic review and cost-effectiveness evaluation

¹

,

²

,

³

et al. 2015

Health Technol Assess

View full text Add to dashboard Cite

BackgroundNon-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.ObjectivesWe 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 sourcesFourteen 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 methodsWe 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.ResultsThe 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.LimitationsThe 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.ConclusionsPre-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 registrationThe study is registered as PROSPERO CRD42012002933.FundingThe National Institute for Health Research Health Technology Assessment programme.

Advanced biostatistics

2015

Doing Research in Emergency and Acute Care

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Respiratory distress

Oost¹,

2015

Emergency Medical Services

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