Continuous positive airway pressure and noninvasive ventilation in prehospital treatment of patients with acute respiratory failure: a systematic review of controlled studies.

Skule A Bakke,Erika F Christensen,Ingunn S Riddervold,Morten T Botker,Hans Kirkegaard

doi:10.1186/s13049-014-0069-8

Abstract

Continuous positive airway pressure (CPAP) and noninvasive ventilation (NIV) are frequently used inhospital for treating respiratory failure, especially in treatment of acute cardiogenic pulmonary edema and exacerbation of chronic obstructive pulmonary disease. Early initiation of treatment is important for success and introduction already in the prehospital setting may be beneficial. Our goal was to assess the evidence for an effect of prehospital CPAP or NIV as a supplement to standard medical treatment alone on the following outcome measures; mortality, hospital length of stay, intensive care unit length of stay, and intubation rate. We undertook a systematic review based on a search in the three databases: PubMed, EMBASE, and Cochrane. We included 12 studies in our review, but only four of these were of acceptable size and quality to conclude on our endpoints of interest. All four studies examine prehospital CPAP. Of these, only one small, randomized controlled trial shows a reduced mortality rate and a reduced intubation rate with supplemental CPAP. The other three studies have neutral findings, but in two of these a trend toward lower intubation rate is found. The effect of supplemental NIV has only been evaluated in smaller studies with insufficient power to conclude on our endpoints. None of these studies have shown an effect on neither mortality nor intubation rate, but two small, randomized controlled trials show a reduction in intensive care unit length of stay and a trend toward lower intubation rate. The risk of both type two errors and publication bias is evident, and the findings are not consistent enough to make solid conclusion on supplemental prehospital NIV. Large, randomized controlled trials regarding the effect of NIV and CPAP as supplement to standard medical treatment alone, in the prehospital setting, are needed.

Highlights

Dyspnea is a frequent symptom among patients in the prehospital setting [1]
Continuous positive airway pressure (CPAP) and noninvasive ventilation (NIV) are often used in intensive care units for treating respiratory failure caused by acute cardiogenic pulmonary edema (ACPE) and acute exacerbation of chronic obstructive pulmonary disease (COPD)
Our inclusion criteria were: Controlled studies examining the effect of supplemental prehospital CPAP or NIV, compared to standard medical treatment alone, in adult patients with acute respiratory failure of any cause

Summary

Introduction

Common causes of nontraumatic dyspnea are congestive heart failure, pneumonia, chronic obstructive pulmonary disease, and asthma [1]. Continuous positive airway pressure (CPAP) and noninvasive ventilation (NIV) are often used in intensive care units for treating respiratory failure caused by acute cardiogenic pulmonary edema (ACPE) and acute exacerbation of chronic obstructive pulmonary disease (COPD). CPAP-systems apply positive airway pressure with only minimal differences in the pressure applied during inspiration and expiration [3]. Standard medical treatment given for acute respiratory failure is diverse, depending on assumed cause and type of emergency medical staffing. It ranges from simple supplemental oxygen therapy to nitrates, diuretics, opioids, inhaled bronchodilators, and inotropic infusions.

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