Abstract
Background: Acute cardiogenic pulmonary edema (ACPE) is characterized by acute breathlessness and hypoxia and is associated with poor prognosis. Standard pre-hospital management of ACPE includes high-flow oxygen, nitroglycerin and, in severe cases, assisted ventilation. Patients with ACPE can be supported with newer modalities of non-invasive ventilation, specifically continuous positive airway pressure (CPAP). The aim of this study was to determine whether patients with ACPE treated with CPAP plus low-flow oxygen pre-hospitally have a lower mortality rate than those treated conventionally. Methods: This study was a pre-hospital randomised, non-blinded controlled trial conducted July 2009–July 2010. Included were all participants transported by ambulance and admitted to the Royal Hobart Hospital, Tasmania, Australia. The study population was consecutive persons ≥18 years of age with sudden onset of severe respiratory distress, diagnosed as ACPE. Patients were included if they required ventilatory assistance. Patients required a GCS >12 and blood pressure >90 mmHg systolic to safely receive CPAP. The primary outcome was pre- or in-hospital mortality. Results: In total, 50 patients were enrolled with mean age of 79.8 (±11.9) years. There were two deaths (8.3%) in the CPAP arm and nine (34.6%) in the control arm (RR, −0.24; 95% CI, 0.06–1.00; p=0.051) with a number needed to treat of 4. CPAP plus low-flow oxygen was significantly less likely to result in respiratory acidosis (mean difference in pH, −0.11; 95% CI, −0.04–−0.17; p=0.002), with elevated pCO2 (mean difference, −10.0 mmHg; 95% CI, −19.2–−0.78; p=0.026). The length of hospital stay was significantly shorter in the surviving patients who received CPAP (ratio of means, 0.45; 95% CI, 0.29–0.70; p≤0.001). Discussion: This study, which provides interim results due to early termination of the trial, shows CPAP in the pre-hospital setting for ACPE is practicable and is associated with improved patient outcomes.
Highlights
Congestive heart failure occurred in 5.7 million Americans1, and in 10 million Europeans2
Baseline characteristics in the two groups were similar for age, initial oxygen saturation, respiratory rate, blood pressure, heart rate, Glasgow Coma Score (GCS) score and pre-hospital treatment time; there were more females in the continuous positive airway pressure (CPAP) arm (Table 1)
Emergency Department (ED) diagnosis confirmed the opinion of the ambulance personnel for all patients enrolled as Acute cardiogenic pulmonary edema (ACPE), and this was endorsed by a later review of investigator notes
Summary
Congestive heart failure occurred in 5.7 million Americans, and in 10 million Europeans. Standard pre-hospital management of ACPE in most ambulance/ paramedic services throughout the world includes high-flow oxygen, nitroglycerin and, in severe cases, assisted ventilation with a bag valve mask or endotracheal intubation (ETI). Standard pre-hospital management of ACPE includes high-flow oxygen, nitroglycerin and, in severe cases, assisted ventilation. The aim of this study was to determine whether patients with ACPE treated with CPAP plus low-flow oxygen pre-hospitally have a lower mortality rate than those treated conventionally. CPAP plus low-flow oxygen was significantly less likely to result in respiratory acidosis (mean difference in pH, −0.11; 95% CI, −0.04–−0.17; p=0.002), with elevated pCO2 (mean difference, −10.0 mmHg; 95% CI, −19.2–−0.78; p=0.026). Discussion: This study, which provides interim results due to early termination of the trial, shows CPAP in the pre-hospital setting for ACPE is practicable and is associated with improved patient outcomes
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