Prehospital noninvasive pressure support ventilation for acute cardiogenic pulmonary edema

Abstract

Severe acute cardiogenic pulmonary edema (ACPE) can successfully be treated with noninvasive pressure support ventilation (NIPSV) in a clinical setting. Whether prehospital NIPSV starting early at patients' home and being continued until hospital arrival is feasible and improves ACPE emergency care is examined in this study. End points of the study were oxygen saturation at hospital admission and clinical outcome. Twenty-three patients suffering from severe cardiac pulmonary edema with severe dyspnea, an oxygen saturation of less than 90% and basal rales were included in this controlled prospective randomized trial. All patients received standard medical treatment and 10 patients were additionally treated with NIPSV (pressure support level, 12 cmH2O; positive endexpiratory pressure, 5 cmH2O; FiO2, 0.6) whereas the other patients received oxygen (8 l/min) via Venturi face mask. Improvement in oxygen saturation was significantly faster in the NIPSV group and oxygen saturation was higher at the time of the hospital admission (NIPSV=97.3+/-0.8%; standard=89.5+/-2.7%, P=0.002). A trend toward higher troponin T levels was seen in the standard treatment group. The need for intensive care treatment did not differ, and one patient of each treatment group died in hospital. No complications were noted during the treatment with NIPSV. Prehospital NIPSV is feasible and able to improve emergency management of ACPE.

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

“…Of these, eight RCTs 46-53 and two quasi-randomised trials 54,55 met the inclusion criteria. A flow chart describing the process of identifying relevant literature can be found in Figure 2.…”

“…While one study, that of Plaisance et al, 50 compared the effectiveness of early CPAP (where patients had CPAP for the first 15 minutes after study inclusion, followed by CPAP with medical treatment for 15 minutes) with late CPAP (where patients received conventional medical treatment with supplementary oxygen for the first 15 minutes of study inclusion, followed by the addition of CPAP for another 15 minutes), five studies [46][47][48]52,53 provided CPAP to patients in the intervention group while patients in the control group received conventional medical treatment only. Of the four studies 49,51,54,55 that assessed the use of BiPAP versus standard usual care, two were quasi-randomised trials. 54,55 In the study by Roessler et al, 51 NIV was initially started with CPAP; however, this was quickly changed to BiPAP, if CPAP was tolerated (22 of 24 patients in the intervention group).…”

“…The design and patient characteristics of the 10 included studies [46][47][48][49][50][51][52][53][54][55] that evaluated the effectiveness of pre-hospital NIV for adults with acute respiratory failure are summarised in Tables 1-3 Of the 10 studies, only one study 55 recieved funding from one or more commercial sponsors. The design of the included studies required the continuation of management of respiratory failure in the hospital setting and in-hospital management was generally at the discretion of the treating physicians.…”

“…spontaneously breathing patients), there was wide variation in terms of underlying conditions resulting in respiratory failure. Six studies [46][47][48]50,54,55 included a selected population of patients with ACPO. Of these, two studies 47,50 documented the exclusion of patients with COPD.…”

“…One study 53 enrolled a diverse population, including patients with chronic heart failure, COPD, asthma, pneumonia and acute coronary syndrome with respiratory failure. The sample sizes of the included studies ranged from 23 patients 55 to 207 patients, 47 with the mean age of participants ranging from 68 years 53 to 80 years. 46,47 The percentage of male participants ranged from 41% 47 to 56%.…”