Effectiveness and safety of a prehospital program of continuous positive airway pressure (CPAP) in an urban setting
Effectiveness and safety of a prehospital program of continuous positive airway pressure (CPAP) in an urban setting
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DOI：
10.1017/cem.2014.60
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发表时间：
2015-11-01
影响因子：
2.4
通讯作者：
Stiell, Ian
中科院分区：
文献类型：
--
作者：
Willmore, Andrew;Dionne, Richard;Stiell, Ian
背景：持续气道正压通气（CPAP）常用于急性心源性肺水肿（ACPE）和慢性阻塞性肺疾病（AECOPD）急性加重期的治疗。住院证据是可靠的：CPAP已被证明可以改善呼吸状态并降低插管率。院前CPAP的证据较少，尽管急诊医疗服务（EMS）对这种模式的采用正在增加。本研究的目的是：1)测量院前CPAP对发病率、死亡率和转运时间的影响；2)审核医务人员选择患者的适当性和安全性。方法：对2010年和2011年8月1日至10月31日在某百万人口的大型农村城市实施院前CPAP前后进行对比研究。医务人员接受培训，对呼吸窘迫和假定诊断为ACPE或AECOPD的患者应用CPAP。使用主诉呼吸短促、紧急送往医院和任何在现场接受CPAP的患者的搜索标准选择图表。从救护车呼叫报告和医院记录中提取的数据用适当的单变量统计进行分析。结果：共纳入373例患者（无创通气前186例，无创通气后187例），平均年龄71.5岁，女性51.4%，最终诊断为ACPE 18.9%, AECOPD 21.9%。后组84例符合NIV标准的患者中，41.6%接受了NIV；在102例不符合标准的患者中，5.2%接受了NIV。36例患者（33.3%）出现12例轻微不良事件。与术前相比，术后急诊科（ED） NIV发生率更高（20.0% vs 13.4%, p < 0.0001），总死亡率更高（18.8% vs 14.9%, p < 0.0001）。两组在ED插管（2.1% vs . 2.3%, p < 0.001）和住院时间（6.8 vs . 8.7天，p = 0.24）方面无差异。结论：尽管有强有力的院内数据支持其使用，但我们在院前设置中未发现CPAP在发病率、死亡率和住院时间方面的益处。EMS在决定是否投资于实施院前CPAP所需的设备和培训时必须谨慎。
Background: Continuous positive airway pressure (CPAP) is commonly used in the treatment of acute cardiogenic pulmonary edema (ACPE) and acute exacerbations of chronic obstructive pulmonary disease (AECOPD). In-hospital evidence is robust: CPAP has been shown to improve respiratory status and to reduce intubation rates. There is less evidence on prehospital CPAP, although the emergency medical services (EMS) adoption of this modality is increasing. The objectives of this study were to 1) measure the effectiveness of prehospital CPAP on morbidity, mortality, and transport times; and 2) audit the selection of patients by medics for appropriateness and safety.Methods: We conducted a before-and-after study from August 1 to October 31 in 2010 and 2011, before and after the implementation of prehospital CPAP in a city of one million people with large rural areas. Medics were trained to apply CPAP to patients with respiratory distress and a presumed diagnosis of ACPE or AECOPD. Charts were selected using the search criteria of the chief complaint of shortness of breath, emergent transport to hospital, and any patients receiving CPAP in the field. Data extracted from ambulance call reports and hospital records were analysed with appropriate univariate statistics.Results: A total of 373 patients enrolled (186 pre-non-invasive ventilation [NIV] and 187 post-NIV), mean age 71.5 years, female 51.4%, and final diagnoses of ACPE 18.9%, AECOPD 21.9%. In the post group of 84 patients meeting NIV criteria, 41.6% received NIV; and of 102 patients not meeting the criteria, 5.2% received NIV. There were 12 minor adverse events in 36 applications (33.3%) as per protocol. Comparing post versus pre, there were higher rates of emergency department (ED) NIV (20.0% v. 13.4%, p < 0.0001) and higher overall mortality (18.8% v. 14.9%, p < 0.0001). There were no differences in ED intubation (2.1% v. 2.3%, p < 0.001) and length of stay (6.8 v. 8.7 days, p = 0.24).Conclusion: Despite the robust in-hospital data supporting its use, we could not find benefit from CPAP in our prehospital setting with respect to morbidity, mortality, and length of stay. EMS must exercise caution in making the decision to invest in the equipment and training required to implement prehospital CPAP.