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Capsoni N, Zadek F, Privitera D, Parravicini G, Zoccali GV, Galbiati F, Bombelli M, Fumagalli R, Langer T. Helmet continuous positive airway pressure for patients' transport using a single oxygen cylinder: A bench study. Pulmonology 2023:S2531-0437(23)00171-X. [PMID: 37903684 DOI: 10.1016/j.pulmoe.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/12/2023] [Accepted: 09/13/2023] [Indexed: 11/01/2023] Open
Abstract
BACKGROUND Continuous positive airway pressure (CPAP) is frequently used to treat patients with acute respiratory failure in out-of-hospital settings. Compared to a facemask, the helmet has many advantages for the patient but requires a minimum gas flow of 60 L/min to avoid CO2 rebreathing. The aim of the present bench study was to evaluate the performance of four Venturi devices, connected to a single oxygen cylinder, in delivering helmet-CPAP with clinically relevant gas flow, fraction of inspired oxygen (FiO2), and positive end-expiratory pressure (PEEP) values. METHODS Three double-inlet Venturi systems (EasyVent, Ventuplus, Compact-HAR) were connected to full 5-L oxygen cylinders using a double flowmeter, and their oxygen requirements to reach different setups (flow 60-80 L/min; FiO2 0.4-0.5-0.6, PEEP 7.5-10-12.5 cmH2O) were tested. The fourth Venturi system (O2-MAX) was directly attached to the tank, and the flow and FiO2 delivered at preset FiO2 0.3 and 0.6 were recorded. The runtime of the cylinder was assessed. RESULTS EasyVent, Ventuplus, and O2-MAX were able to deliver helmet-CPAP with clinically useful setups when connected to a single oxygen cylinder, while Compact-HAR did not. The runtime of the cylinders ranged between 28 and 60 minutes according to the preset flow and FiO2. The delivered gas flow decreased slowly and linearly with the drop in cylinder pressure until its exhaustion. CONCLUSIONS Helmet-CPAP might be provided using portable Venturi systems connected to an oxygen cylinder, but not all of them are able to deliver it. The use of a double flowmeter allows delivery of both high flow and high FiO2 when double-inlet Venturi systems are used. Due to the flow drop observed during the cylinder consumption, a flow >60 L/min should be set when helmet-CPAP is started. Considering the flow drop phenomenon, the estimated duration of the tank runtime can be used with a margin of safety when planning patient transport.
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Affiliation(s)
- N Capsoni
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.
| | - F Zadek
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - D Privitera
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - G Parravicini
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - G V Zoccali
- Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milan, Italy
| | - F Galbiati
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - M Bombelli
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - R Fumagalli
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy; Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milan, Italy
| | - T Langer
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy; Department of Anesthesia and Intensive Care Medicine, Niguarda Ca' Granda, Milan, Italy
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Pinto-Villalba RS, Leon-Rojas JE. Reported adverse events during out-of-hospital mechanical ventilation and ventilatory support in emergency medical services and critical care transport crews: a systematic review. Front Med (Lausanne) 2023; 10:1229053. [PMID: 37877027 PMCID: PMC10590890 DOI: 10.3389/fmed.2023.1229053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 09/20/2023] [Indexed: 10/26/2023] Open
Abstract
Background Emergency medical services (EMS) and critical care transport crews constantly face critically-ill patients who need ventilatory support in scenarios where correct interventions can be the difference between life and death; furthermore, challenges like limited staff working on the patient and restricted spaces are often present. Due to these, mechanical ventilation (MV) can be a support by liberating staff from managing the airway and allowing them to focus on other areas; however, these patients face many complications that personnel must be aware of. Aims To establish the main complications related to out-of-hospital MV and ventilatory support through a systematic review. Methodology PubMed, BVS and Scopus were searched from inception to July 2021, following the PRISMA guidelines; search strategy and protocol were registered in PROSPERO. Two authors carried out an independent analysis of the articles; any disagreement was solved by mutual consensus, and data was extracted on a pre-determined spreadsheet. Only original articles were included, and risk of bias was assessed with quality assessment tools from the National Institutes of Health. Results The literature search yielded a total of 2,260 articles, of which 26 were included in the systematic review, with a total of 9,418 patients with out-of-hospital MV; 56.1% were male, and the age ranged from 18 to 82 years. In general terms of aetiology, 12.2% of ventilatory problems were traumatic in origin, and 64.8% were non-traumatic, with slight changes between out-of-hospital settings. Mechanical ventilation was performed 49.2% of the time in prehospital settings and 50.8% of the time in interfacility transport settings (IFTS). Invasive mechanical ventilation was used 98.8% of the time in IFTS while non-invasive ventilation was used 96.7% of the time in prehospital settings. Reporting of adverse events occurred in 9.1% of cases, of which 94.4% were critical events, mainly pneumothorax in 33.1% of cases and hypotension in 27.6% of cases, with important considerations between type of out-of-hospital setting and ventilatory mode; total mortality was 8.4%. Conclusion Reported adverse events of out-of-hospital mechanical ventilation vary between settings and ventilatory modes; this knowledge could aid EMS providers in promptly recognizing and resolving such clinical situations, depending on the type of scenario being faced.
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Affiliation(s)
- Ricardo Sabastian Pinto-Villalba
- Carrera de Atención Prehospitalaria y en Emergencias, Universidad Central del Ecuador, Quito, Ecuador
- Facultad de Medicina, Carrera de Atención Prehospitalaria y en Emergencias, Universidad UTE, Quito, Ecuador
- Medignosis, Medical Research Department, Quito, Ecuador
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Scquizzato T, Imbriaco G, Moro F, Losiggio R, Cabrini L, Consolo F, Landoni G, Zangrillo A. Non-Invasive Ventilation in the Prehospital Emergency Setting: A Systematic Review and Meta-Analysis. PREHOSP EMERG CARE 2022:1-9. [PMID: 35695184 DOI: 10.1080/10903127.2022.2086331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Noninvasive ventilation is a well-established treatment for acute respiratory failure, being increasingly applied in the prehospital setting. This systematic review and meta-analysis aims to investigate whether early prehospital initiation of noninvasive ventilation reduces mortality compared to standard oxygen therapy. METHODS We searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials from inception to February 7th, 2022, for studies comparing prehospital noninvasive ventilation performed by emergency medical services versus standard oxygen therapy in patients with acute respiratory failure. The primary outcome was mortality at the longest follow-up available. RESULTS We included ten randomized studies and two quasi-randomized studies for a total of 1485 patients. Prehospital treatment with noninvasive ventilation compared with standard oxygen therapy did not significantly reduce mortality at the longest follow-up available (107/810 [13%] vs 114/772 [15%]; RR = 0.89; 95% CI, 0.70-1.13; P = 0.34; I2=24%). The endotracheal intubation rate was reduced when receiving prehospital noninvasive ventilation (38/776 [4.9%] vs 81/743 [11%]; RR = 0.44; 95% CI, 0.31-0.63; P < 0.001; I2=0%; number needed to treat 17). The intensive care admission rate (114/532 [21%] vs 129/507 [25%]; RR = 0.85; 95% CI, 0.69-1.04; P = 0.11; I2=0%) and length of hospital stay (mean difference=-1.29 days; 95% CI, -3.35-0.77; P = 0.21; I2=82%) were similar between groups. CONCLUSIONS Adults with acute respiratory failure treated in the prehospital setting with noninvasive ventilation had a lower risk of intubation than those managed with standard oxygen therapy, with similar risk of death, intensive care admission, and length of hospital stay. REVIEW REGISTRATION PROSPERO CRD42021284947.
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Affiliation(s)
- Tommaso Scquizzato
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Guglielmo Imbriaco
- Centrale Operativa 118 Emilia Est, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy.,Critical Care Nursing Master Course, University of Bologna, Bologna, Italy
| | - Federico Moro
- Department of Anaesthesia, Intensive Care and Emergency Medical Services, Ospedale Maggiore, Bologna, Italy
| | - Rosario Losiggio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luca Cabrini
- Department of Biology and Life Sciences, Ospedale di Circolo e Fondazione Macchi, University of Insubria, Varese, Italy
| | - Filippo Consolo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Faculty of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Faculty of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Faculty of Medicine, Vita-Salute San Raffaele University, Milan, Italy
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Non-Invasive Ventilation as a Therapy Option for Acute Exacerbations of Chronic Obstructive Pulmonary Disease and Acute Cardiopulmonary Oedema in Emergency Medical Services. J Clin Med 2022; 11:jcm11092504. [PMID: 35566628 PMCID: PMC9102097 DOI: 10.3390/jcm11092504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/24/2022] [Accepted: 04/26/2022] [Indexed: 11/16/2022] Open
Abstract
In this observational prospective multicenter study conducted between October 2016 and October 2018, we tested the hypothesis that the use of prehospital non-invasive ventilation (phNIV) to treat patients with acute respiratory insufficiency (ARI) caused by severe acute exacerbations of chronic obstructive pulmonary disease (AECOPD) and acute cardiopulmonary oedema (ACPE) is effective, time-efficient and safe. The data were collected at four different physician response units and three admitting hospitals in a German EMS system. Patients with respiratory failure due to acute exacerbation of chronic obstructive pulmonary disease and acute cardiopulmonary oedema were enrolled. A total of 545 patients were eligible for the final analysis. Patients were treated with oxygen supplementation, non-invasive ventilation or invasive mechanical ventilation. The primary outcomes were defined as changes in the clinical parameters and the in-hospital course. The secondary outcomes included time efficiency, peri-interventional complications, treatment failure rate, and side-effects. Oxygenation under phNIV improved equally to endotracheal intubation (ETI), and more effectively in comparison to standard oxygen therapy (SOT) (paO2 SOT vs. non-invasive ventilation (NIV) vs. ETI: 82 mmHg vs. 125 mmHg vs. 135 mmHg, p-value SOT vs. NIV < 0.0001). In a matched subgroup analysis phNIV was accompanied by a reduced time of mechanical ventilation (phNIV: 1.8 d vs. ETI: 4.2 d) and a shortened length of stay at the intensive care unit (3.4 d vs. 5.8 d). The data support the hypothesis that the treatment of severe AECOPD/ACPE-induced ARI using prehospital NIV is effective, time efficient and safe. Compared to ETI, a matched comparison supports the hypothesis that prehospital implementation of NIV may provide benefits for an in-hospital course.
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Meng M, Zhang J, Chen L, Wang L. Prehospital noninvasive positive pressure ventilation for severe respiratory distress in adult patients: An updated meta-analysis. J Clin Nurs 2022; 31:3327-3337. [PMID: 35212078 DOI: 10.1111/jocn.16224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 12/19/2021] [Accepted: 01/04/2022] [Indexed: 12/30/2022]
Abstract
AIM To compare the effect of prehospital noninvasive positive pressure ventilation (NIPPV) and standard care for severe respiratory distress. BACKGROUND Severe respiratory distress is an important cause of death in adult patients. There is a growing body of research exploring the benefits of nasal intermittent positive pressure ventilation (NIPPV) for patients undergoing severe respiratory distress. However, a systematic review is needed to synthesise and summarise this body of knowledge to identify the effectiveness of NIPPV. This is an update of a meta-analysis first published in 2014. DESIGN Meta-analysis based on PRISMA guidelines. METHODS Databases including PubMed, Embase, Scopus and the Cochrane Library databases were electronically searched to identify randomised controlled trials (RCTs) that reported NIPPV therapy for adult patients with severe respiratory distress. The retrieval time is limited from inception to August 2021. Two reviewers independently screened literature, extracted data and assessed risk bias of included studies. Meta-analysis was performed by using STATA 11.0 software. RESULTS A total of 10 studies involving 1465 patients were included. The meta-analysis results showed that compared with standard care, CPAP therapy decreased intubation rate (RR = 0.43, 95% CI: 0.27-0.67, p < .001, I2 = 0.0%), reduced hospital stay (WMD = -4.19, 95% CI: -5.62, -2.77) and ICU stay (WMD = -0.65, 95% CI: -1.09, -0.20) for patients with severe respiratory distress. However, no significant effects of NIPPV were observed on in-hospital mortality (RR = 0.83, 95% CI: 0.64-1.07) and ICU admission rate (RR = 0.93, 95% CI: 0.73-1.19). CONCLUSIONS Adult patients with NIPPV treatment for severe respiratory distress had a significantly lower intubation rate and shorter hospital and ICU stay, compared with those with standard care. However, no effect of NIPPV on in-hospital mortality was observed. Further study is needed by enrolling large-sample original studies. RELEVANCE TO CLINICAL PRACTICE Among patients with severe respiratory distress, prehospital NIPPV, compared with standard care, was associated with lower intubation rate and shorter hospital and ICU stay in our study. Although our meta-analysis did not find a relationship between prehospital NIPPV and in-hospital mortality and ICU admission rate, which may be limited by the number of studies included and the small sample size. However, our study still suggested that the use of prehospital NIPPV was beneficial to the condition of patients with severe respiratory distress.
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Affiliation(s)
- Meng Meng
- Nursing Department of the Eighth Medical Center of PLA General Hospital, Beijing, China
| | - Junhong Zhang
- Department of Respiratory and Critical Care Medicine, The Eighth Medical Center of PLA General Hospital, Beijing, China
| | - Liying Chen
- Department of Respiratory and Critical Care Medicine, The Eighth Medical Center of PLA General Hospital, Beijing, China
| | - Liqin Wang
- Nursing Department of the Eighth Medical Center of PLA General Hospital, Beijing, China
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McCoy AM, Morris D, Tanaka K, Wright A, Guyette FX, Martin-Gill C. Prehospital Noninvasive Ventilation: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:80-87. [PMID: 35001825 DOI: 10.1080/10903127.2021.1993392] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Noninvasive ventilation (NIV), including bilevel positive airway pressure and continuous positive airway pressure, is a safe and important therapeutic option in the management of prehospital respiratory distress. NAEMSP recommends:NIV should be used in the management of prehospital patients with respiratory failure, such as those with chronic obstructive pulmonary disease, asthma, and pulmonary edema.NIV is a safe intervention for use by Emergency Medical Technicians.Medical directors must assure adequate training in NIV, including appropriate patient selection, NIV system operation, administration of adjunctive medications, and assessment of clinical response.Medical directors must implement quality assessment and improvement programs to assure optimal application of and outcomes from NIV.Novel NIV methods such as high-flow nasal cannula and helmet ventilation may have a role in prehospital care.
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Gottlieb J, Capetian P, Hamsen U, Janssens U, Karagiannidis C, Kluge S, Nothacker M, Roiter S, Volk T, Worth H, Fühner T. German S3 Guideline: Oxygen Therapy in the Acute Care of Adult Patients. Respiration 2021; 101:214-252. [PMID: 34933311 DOI: 10.1159/000520294] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 10/06/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Oxygen (O2) is a drug with specific biochemical and physiological properties, a range of effective doses and may have side effects. In 2015, 14% of over 55,000 hospital patients in the UK were using oxygen. 42% of patients received this supplemental oxygen without a valid prescription. Health care professionals are frequently uncertain about the relevance of hypoxemia and have low awareness about the risks of hyperoxemia. Numerous randomized controlled trials about targets of oxygen therapy have been published in recent years. A national guideline is urgently needed. METHODS A national S3 guideline was developed and published within the Program for National Disease Management Guidelines (AWMF) with participation of 10 medical associations. A literature search was performed until February 1, 2021, to answer 10 key questions. The Oxford Centre for Evidence-Based Medicine (CEBM) System ("The Oxford 2011 Levels of Evidence") was used to classify types of studies in terms of validity. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for assessing the quality of evidence and for grading guideline recommendation, and a formal consensus-building process was performed. RESULTS The guideline includes 34 evidence-based recommendations about indications, prescription, monitoring and discontinuation of oxygen therapy in acute care. The main indication for O2 therapy is hypoxemia. In acute care both hypoxemia and hyperoxemia should be avoided. Hyperoxemia also seems to be associated with increased mortality, especially in patients with hypercapnia. The guideline provides recommended target oxygen saturation for acute medicine without differentiating between diagnoses. Target ranges for oxygen saturation are based depending on ventilation status risk for hypercapnia. The guideline provides an overview of available oxygen delivery systems and includes recommendations for their selection based on patient safety and comfort. CONCLUSION This is the first national guideline on the use of oxygen in acute care. It addresses health care professionals using oxygen in acute out-of-hospital and in-hospital settings.
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Affiliation(s)
- Jens Gottlieb
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Philipp Capetian
- Department of Neurology, University Hospital Würzburg, Wuerzburg, Germany
| | - Uwe Hamsen
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bochum, Germany
| | - Uwe Janssens
- Medical Clinic and Medical Intensive Care Medicine, St. Antonius Hospital, Eschweiler, Germany
| | - Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken der Stadt Köln, Witten/Herdecke University Hospital, Cologne, Germany
| | - Stefan Kluge
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Monika Nothacker
- AWMF-Institute for Medical Knowledge Management, Marburg, Germany
| | - Sabrina Roiter
- Intensive Care Unit, Israelite Hospital Hamburg, Hamburg, Germany
| | - Thomas Volk
- Department of Anesthesiology, University Hospital of Saarland, Saarland University, Homburg, Germany
| | | | - Thomas Fühner
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany.,Department of Respiratory Medicine, Siloah Hospital, Hannover, Germany
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8
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Masip J. Non-invasive ventilation in acute pulmonary oedema: does the technique or the interface matter? EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2021; 10:1112-1116. [PMID: 34849646 DOI: 10.1093/ehjacc/zuab096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Affiliation(s)
- Josep Masip
- Research Direction, Consorci Sanitari Integral, University of Barcelona, Av. Josep Molins, 29, 08906 L'Hospitalet de Llobregat, Barcelona, Spain
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9
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Mistry S, Das A, Hardman JG, Bates DG, Scott TE. Pre-hospital continuous positive airway pressure after blast lung injury and hypovolaemic shock: a modelling study. Br J Anaesth 2021; 128:e151-e157. [PMID: 34863511 DOI: 10.1016/j.bja.2021.10.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 10/14/2021] [Accepted: 10/14/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND In non-traumatic respiratory failure, pre-hospital application of CPAP reduces the need for intubation. Primary blast lung injury (PBLI) accompanied by haemorrhagic shock is common after mass casualty incidents. We hypothesised that pre-hospital CPAP is also beneficial after PBLI accompanied by haemorrhagic shock. METHODS We performed a computer-based simulation of the cardiopulmonary response to PBLI followed by haemorrhage, calibrated from published controlled porcine experiments exploring blast injury and haemorrhagic shock. The effect of different CPAP levels was simulated in three in silico patients who had sustained mild, moderate, or severe PBLI (10%, 25%, 50% contusion of the total lung) plus haemorrhagic shock. The primary outcome was arterial partial pressure of oxygen (Pao2) at the end of each simulation. RESULTS In mild blast lung injury, 5 cm H2O ambient-air CPAP increased Pao2 from 10.6 to 12.6 kPa. Higher CPAP did not further improve Pao2. In moderate blast lung injury, 10 cm H2O CPAP produced a larger increase in Pao2 (from 8.5 to 11.1 kPa), but 15 cm H2O CPAP produced no further benefit. In severe blast lung injury, 5 cm H2O CPAP inceased Pao2 from 4.06 to 8.39 kPa. Further increasing CPAP to 10-15 cm H2O reduced Pao2 (7.99 and 7.90 kPa, respectively) as a result of haemodynamic impairment resulting from increased intrathoracic pressures. CONCLUSIONS Our modelling study suggests that ambient air 5 cm H2O CPAP may benefit casualties suffering from blast lung injury, even with severe haemorrhagic shock. However, higher CPAP levels beyond 10 cm H2O after severe lung injury reduced oxygen delivery as a result of haemodynamic impairment.
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Affiliation(s)
- Sonal Mistry
- School of Engineering, University of Warwick, Coventry, UK
| | - Anup Das
- School of Engineering, University of Warwick, Coventry, UK
| | - Jonathan G Hardman
- Anaesthesia and Critical Care, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK
| | - Declan G Bates
- School of Engineering, University of Warwick, Coventry, UK.
| | - Timothy E Scott
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, ICT Centre, Birmingham, UK.
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Gottlieb J, Capetian P, Hamsen U, Janssens U, Karagiannidis C, Kluge S, König M, Markewitz A, Nothacker M, Roiter S, Unverzagt S, Veit W, Volk T, Witt C, Wildenauer R, Worth H, Fühner T. [German S3 Guideline - Oxygen Therapy in the Acute Care of Adult Patients]. Pneumologie 2021; 76:159-216. [PMID: 34474487 DOI: 10.1055/a-1554-2625] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Oxygen (O2) is a drug with specific biochemical and physiologic properties, a range of effective doses and may have side effects. In 2015, 14 % of over 55 000 hospital patients in the UK were using oxygen. 42 % of patients received this supplemental oxygen without a valid prescription. Healthcare professionals are frequently uncertain about the relevance of hypoxemia and have low awareness about the risks of hyperoxemia. Numerous randomized controlled trials about targets of oxygen therapy have been published in recent years. A national guideline is urgently needed. METHODS A S3-guideline was developed and published within the Program for National Disease Management Guidelines (AWMF) with participation of 10 medical associations. Literature search was performed until Feb 1st 2021 to answer 10 key questions. The Oxford Centre for Evidence-Based Medicine (CEBM) System ("The Oxford 2011 Levels of Evidence") was used to classify types of studies in terms of validity. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used and for assessing the quality of evidence and for grading guideline recommendation and a formal consensus-building process was performed. RESULTS The guideline includes 34 evidence-based recommendations about indications, prescription, monitoring and discontinuation of oxygen therapy in acute care. The main indication for O2 therapy is hypoxemia. In acute care both hypoxemia and hyperoxemia should be avoided. Hyperoxemia also seems to be associated with increased mortality, especially in patients with hypercapnia. The guideline provides recommended target oxygen saturation for acute medicine without differentiating between diagnoses. Target ranges for oxygen saturation are depending on ventilation status risk for hypercapnia. The guideline provides an overview of available oxygen delivery systems and includes recommendations for their selection based on patient safety and comfort. CONCLUSION This is the first national guideline on the use of oxygen in acute care. It addresses healthcare professionals using oxygen in acute out-of-hospital and in-hospital settings. The guideline will be valid for 3 years until June 30, 2024.
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Affiliation(s)
- Jens Gottlieb
- Klinik für Pneumologie, Medizinische Hochschule Hannover.,Biomedical Research in End-stage and Obstructive Lung Disease Hannover (BREATH) im Deutschen Zentrum für Lungenforschung (DZL)
| | - Philipp Capetian
- Klinik für Neurologie, Neurologische Intensivstation, Universitätsklinikum Würzburg
| | - Uwe Hamsen
- Fachbereich für Unfallchirurgie und Orthopädie, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bochum
| | - Uwe Janssens
- Innere Medizin und internistische Intensivmedizin, Sankt Antonius Hospital GmbH, Eschweiler
| | - Christian Karagiannidis
- Abteilung für Pneumologie und Beatmungsmedizin, ARDS/ECMO Zentrum, Lungenklinik Köln-Merheim
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Eppendorf, Hamburg
| | - Marco König
- Deutscher Berufsverband Rettungsdienst e. V., Lübeck
| | - Andreas Markewitz
- ehem. Klinik für Herz- und Gefäßchirurgie Bundeswehrzentralkrankenhaus Koblenz
| | - Monika Nothacker
- Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V., Marburg
| | | | | | - Wolfgang Veit
- Bundesverband der Organtransplantierten e. V., Marne
| | - Thomas Volk
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum des Saarlandes, Homburg/Saar
| | - Christian Witt
- Seniorprofessor Innere Medizin und Pneumologie, Charité Berlin
| | | | | | - Thomas Fühner
- Krankenhaus Siloah, Klinik für Pneumologie und Beatmungsmedizin, Klinikum Region Hannover.,Biomedical Research in End-stage and Obstructive Lung Disease Hannover (BREATH) im Deutschen Zentrum für Lungenforschung (DZL)
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Metkus TS, Stephens RS, Schulman S, Hsu S, Morrow DA, Eid SM. Utilization and outcomes of early respiratory support in 6.5 million acute heart failure hospitalizations. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 6:72-80. [PMID: 31225598 DOI: 10.1093/ehjqcco/qcz030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 06/09/2019] [Accepted: 06/13/2019] [Indexed: 12/19/2022]
Abstract
AIMS The incidence and outcomes of a requirement for non-invasive ventilation (NIV) or invasive mechanical ventilation (IMV) in acute heart failure (AHF) hospitalization are not clearly established. Thus, we aimed to characterize the incidence and trends in use of IMV and NIV in AHF and to estimate the magnitude of hazard for mortality associated with requiring IMV and NIV in AHF. METHODS AND RESULTS We used the National Inpatient Sample (NIS) to identify AHF hospitalizations between 2008 and 2014. The exposure variable of interest was IMV or NIV use within 24 h of hospital admission compared to no respiratory support. We analysed the association between ventilation strategies and in-hospital mortality using Cox proportional hazards models adjusting for demographics and comorbidities. We included 6 534 675 hospitalizations for AHF. Of these, 271 589 (4.16%) included NIV and 51 459 (0.79%) included IMV within the first 24 h of hospitalization and rates of NIV and IMV use increased over time. In-hospital mortality for AHF hospitalizations including NIV was 5.0% and 27% for IMV compared with 2.1% for neither (P < 0.001 for both). In an adjusted model, requirement for NIV was associated with over two-fold higher risk for in-hospital mortality [hazard ratio (HR) 2.10, 95% confidence interval (CI) 2.01-2.19; P < 0.001] and requirement for IMV was associated with over three-fold higher risk for in-hospital mortality (HR 3.39, 95% CI 3.14-3.66; P < 0.001). CONCLUSION Respiratory support is used in many AHF hospitalizations, and AHF patients who require respiratory support are at high risk for in-hospital mortality. Our work should inform prospective intervention trials and quality improvement ventures in this high-risk population.
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Affiliation(s)
- Thomas S Metkus
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Blalock 524, D2, 600 N Wolfe St, Baltimore, MD 21287, USA
| | - Robert Scott Stephens
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, 600 N Wolfe St, Baltimore, MD 21287, USA
| | - Steven Schulman
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Blalock 524, D2, 600 N Wolfe St, Baltimore, MD 21287, USA
| | - Steven Hsu
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Blalock 524, D2, 600 N Wolfe St, Baltimore, MD 21287, USA
| | - David A Morrow
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Shaker M Eid
- Department of Medicine, Johns Hopkins University School of Medicine, 4940 Eastern Ave, Baltimore, MD 21224, USA
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Pinczon J, Terzi N, Usseglio-Polatera P, Gheno G, Savary D, Debaty G, Peigne V. Outcomes of Patients Treated with Prehospital Noninvasive Ventilation: Observational Retrospective Multicenter Study in the Northern French Alps. J Clin Med 2021; 10:jcm10071359. [PMID: 33806188 PMCID: PMC8037034 DOI: 10.3390/jcm10071359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 03/19/2021] [Accepted: 03/21/2021] [Indexed: 11/30/2022] Open
Abstract
Noninvasive ventilation (NIV) improves the outcome of acute cardiogenic pulmonary edema (AcPE) and acute exacerbation of chronic obstructive pulmonary disease (aeCOPD) but is not recommended in pneumonia. The aim of this study was to assess the appropriateness of the use of NIV in a prehospital setting, where etiological diagnostics rely mainly on clinical examination. This observational multicenter retrospective study included all the patients treated with NIV by three mobile medical emergency teams in 2015. Prehospital diagnoses and hospital diagnoses were extracted from the medical charts. The appropriateness of NIV was determined by matching the hospital diagnosis to the current guidelines. Among the 14,067 patients screened, 172 (1.2%) were treated with NIV. The more frequent prehospital diagnoses were AcPE (n = 102, 59%), acute respiratory failure of undetermined cause (n = 46, 28%) and aeCOPD (n = 17, 10%). An accurate prehospital diagnosis was more frequent for AcPE (83/88, 94%) than for aeCOPD (14/32, 44%; p < 0.01). Only two of the 25 (8%) pneumonia cases were diagnosed during prehospital management. Prehospital NIV was inappropriate for 32 (21%) patients. Patients with inappropriate NIV had a higher rate of in-hospital intubation than patients with appropriate NIV (38% vs. 8%; p < 0.001). This high frequency of inappropriate NIV could be reduced by an improvement in the prehospital detection of aeCOPD and pneumonia.
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Affiliation(s)
- Julie Pinczon
- SAMU 73, Centre Hospitalier Métropole-Savoie, 73000 Chambéry, France; (J.P.); (P.U.-P.)
| | - Nicolas Terzi
- Medical Intensive Care Unit, University Hospital of Grenoble Alps, 38000 Grenoble, France;
| | | | - Gaël Gheno
- SAMU 74, Centre Hospitalier Annecy Genevois, 74370 Epagny-Metz-Tessy, France;
| | - Dominique Savary
- Emergency Department, CHU d’Angers, University Angers, 49000 Angers, France;
- IRSET (Institut de Recherche en Santé, Environnement et Travail)—UMR_S 1085, University Angers, 49000 Angers, France
| | - Guillaume Debaty
- Emergency Department, SAMU 38, University Hospital of Grenoble Alps and University Grenoble Alps/CNRS/TIMC-IMAG UMR 5525, 38000 Grenoble, France;
| | - Vincent Peigne
- Intensive Care Unit, Centre Hospitalier Métropole-Savoie, 73000 Chambéry, France
- Correspondence: ; Tel.: +33-4-79-96-61-52
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13
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Arfaras-Melainis A, Polyzogopoulou E, Triposkiadis F, Xanthopoulos A, Ikonomidis I, Mebazaa A, Parissis J. Heart failure and sepsis: practical recommendations for the optimal management. Heart Fail Rev 2021; 25:183-194. [PMID: 31227942 DOI: 10.1007/s10741-019-09816-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Acute heart failure (AHF) is a common clinical challenge that a wide spectrum of physicians encounters in every practice. In many cases, AHF is due to decompensation of chronic heart failure. This decompensation may be triggered by various reasons, with sepsis being a notable one. Sepsis is defined as a life-threatening organ dysfunction caused by the dysregulated host response to infection and is associated with a very high mortality, which may reach 25%. Alarmingly, the increase in the mortality rate of patients with combined cardiac dysfunction and sepsis is extremely high (may reach 90%). Thus, these patients need urgent intervention. Management of patients with AHF and sepsis is challenging since cornerstone interventions for AHF may be contraindicated in sepsis and vice versa (e.g., diuretic treatment). Unfortunately, no relevant guidelines are yet available, and treatment remains empirical. This review attempts to shed light on the intricacies of the available interventions and suggests routes of action based on the existing bibliography.
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Affiliation(s)
- Angelos Arfaras-Melainis
- Second Cardiology Department, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, Rimini 1, 122 43, Chaidari, Greece.
| | - Eftihia Polyzogopoulou
- Emergency Medicine Department, Attikon University Hospital, National and Kapodistrian University of Athens, Rimini 1, 122 43, Chaidari, Athens, Greece
| | - Filippos Triposkiadis
- Department of Cardiology, Larissa University General Hospital, 413 34, Larissa, Greece
| | - Andrew Xanthopoulos
- Department of Cardiology, Larissa University General Hospital, 413 34, Larissa, Greece
| | - Ignatios Ikonomidis
- Second Cardiology Department, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, Rimini 1, 122 43, Chaidari, Greece
| | - Alexander Mebazaa
- INSERM UMR-S 942, Université Paris Diderot - PRES Sorbonne Paris Cité, Department of Anesthesiology and Critical Care Medicine, AP-HP Saint Louis and Lariboisière University Hospitals, 2 Rue Ambroise Paré, 75010, Paris, France
| | - John Parissis
- Second Cardiology Department, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, Rimini 1, 122 43, Chaidari, Greece
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14
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Fuller GW, Keating S, Goodacre S, Herbert E, Perkins GD, Rosser A, Gunson I, Miller J, Ward M, Bradburn M, Thokala P, Harris T, Marsh MM, Scott AJ, Cooper C. Prehospital continuous positive airway pressure for acute respiratory failure: the ACUTE feasibility RCT. Health Technol Assess 2021; 25:1-92. [PMID: 33538686 DOI: 10.3310/hta25070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Acute respiratory failure is a life-threatening emergency. Standard prehospital management involves controlled oxygen therapy. Continuous positive airway pressure is a potentially beneficial alternative treatment; however, it is uncertain whether or not this treatment could improve outcomes in NHS ambulance services. OBJECTIVES To assess the feasibility of a large-scale pragmatic trial and to update an existing economic model to determine cost-effectiveness and the value of further research. DESIGN (1) An open-label, individual patient randomised controlled external pilot trial. (2) Cost-effectiveness and value-of-information analyses, updating an existing economic model. (3) Ancillary substudies, comprising an acute respiratory failure incidence study, an acute respiratory failure diagnostic agreement study, clinicians perceptions of a continuous positive airway pressure mixed-methods study and an investigation of allocation concealment. SETTING Four West Midlands Ambulance Service hubs, recruiting between August 2017 and July 2018. PARTICIPANTS Adults with respiratory distress and peripheral oxygen saturations below the British Thoracic Society's target levels were included. Patients with limited potential to benefit from, or with contraindications to, continuous positive airway pressure were excluded. INTERVENTIONS Prehospital continuous positive airway pressure (O-Two system, O-Two Medical Technologies Inc., Brampton, ON, Canada) was compared with standard oxygen therapy, titrated to the British Thoracic Society's peripheral oxygen saturation targets. Interventions were provided in identical sealed boxes. MAIN OUTCOME MEASURES Feasibility objectives estimated the incidence of eligible patients, the proportion recruited and allocated to treatment appropriately, adherence to allocated treatment, and retention and data completeness. The primary clinical end point was 30-day mortality. RESULTS Seventy-seven patients were enrolled (target 120 patients), including seven patients with a diagnosis for which continuous positive airway pressure could be ineffective or harmful. Continuous positive airway pressure was fully delivered to 74% of participants (target 75%). There were no major protocol violations/non-compliances. Full data were available for all key outcomes (target ≥ 90%). Thirty-day mortality was 27.3%. Of the 21 deceased participants, 14 (68%) either did not have a respiratory condition or had ceiling-of-treatment decision implemented that excluded hospital non-invasive ventilation and critical care. The base-case economic evaluation indicated that standard oxygen therapy was probably cost-effective (incremental cost-effectiveness ratio £5685 per quality-adjusted life-year), but there was considerable uncertainty (population expected value of perfect information of £16.5M). Expected value of partial perfect information analyses indicated that effectiveness of prehospital continuous positive airway pressure was the only important variable. The incidence rate of acute respiratory failure was 17.4 (95% confidence interval 16.3 to 18.5) per 100,000 persons per year. There was moderate agreement between the primary prehospital and final hospital diagnoses (Gwet's AC1 coefficient 0.56, 95% confidence interval 0.43 to 0.69). Lack of hospital awareness of the Ambulance continuous positive airway pressure (CPAP): Use, Treatment Effect and economics (ACUTE) trial, limited time to complete trial training and a desire to provide continuous positive airway pressure treatment were highlighted as key challenges by participating clinicians. LIMITATIONS During week 10 of recruitment, the continuous positive airway pressure arm equipment boxes developed a 'rattle'. After repackaging and redistribution, no further concerns were noted. A total of 41.4% of ambulance service clinicians not participating in the ACUTE trial indicated a difference between the control and the intervention arm trial boxes (115/278); of these clinician 70.4% correctly identified box contents. CONCLUSIONS Recruitment rate was below target and feasibility was not demonstrated. The economic evaluation results suggested that a definitive trial could represent value for money. However, limited compliance with continuous positive airway pressure and difficulty in identifying patients who could benefit from continuous positive airway pressure indicate that prehospital continuous positive airway pressure is unlikely to materially reduce mortality. FUTURE WORK A definitive clinical effectiveness trial of continuous positive airway pressure in the NHS is not recommended. TRIAL REGISTRATION Current Controlled Trials ISRCTN12048261. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 7. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Gordon W Fuller
- Centre for Urgent and Emergency Care Research, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Samuel Keating
- Clinical Trials Research Unit, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Steve Goodacre
- Centre for Urgent and Emergency Care Research, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Esther Herbert
- Clinical Trials Research Unit, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Andy Rosser
- West Midlands Ambulance Service, Brierley Hill, UK
| | | | | | - Matthew Ward
- West Midlands Ambulance Service, Brierley Hill, UK
| | - Mike Bradburn
- Clinical Trials Research Unit, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Praveen Thokala
- Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Tim Harris
- Centre for Neuroscience and Trauma, Blizard Institute, Queen Mary University of London, London, UK
| | - Margaret M Marsh
- Sheffield Emergency Care Forum, Royal Hallamshire Hospital, Sheffield, UK
| | - Alexander J Scott
- Clinical Trials Research Unit, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Cindy Cooper
- Clinical Trials Research Unit, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Shiraishi Y, Kawana M, Nakata J, Sato N, Fukuda K, Kohsaka S. Time-sensitive approach in the management of acute heart failure. ESC Heart Fail 2020; 8:204-221. [PMID: 33295126 PMCID: PMC7835610 DOI: 10.1002/ehf2.13139] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/23/2020] [Accepted: 11/11/2020] [Indexed: 12/25/2022] Open
Abstract
Acute heart failure (AHF) has become a global public health burden largely because of the associated high morbidity, mortality, and cost. The treatment options for AHF have remained relatively unchanged over the past decades. Historically, clinical congestion alone has been considered the main target for treatment of acute decompensation in patients with AHF; however, this is an oversimplification of the complex pathophysiology. Within the similar clinical presentation of congestion, significant differences in pathophysiological mechanisms exist between the fluid accumulation and redistribution. Tissue hypoperfusion is another vital characteristic of AHF and should be promptly treated with appropriate interventions. In addition, recent clinical trials of novel therapeutic strategies have shown that heart failure management is ‘time sensitive’ and suggested that treatment selection based on individual aetiologies, triggers, and risk factor profiles could lead to better outcomes. In this review, we aim to describe the specifics of the ‘time‐sensitive’ approach by the clinical phenotypes, for example, pulmonary/systemic congestion and tissue hypoperfusion, wherein patients are classified based on pathophysiological conditions. This mechanistic classification, in parallel with the comprehensive risk assessment, has become a cornerstone in the management of patients with AHF and thus supports effective decision making by clinicians. We will also highlight how therapeutic modalities should be individualized according to each clinical phenotype.
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Affiliation(s)
- Yasuyuki Shiraishi
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Masataka Kawana
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, CA, USA
| | - Jun Nakata
- Division of Intensive and Cardiovascular Care Unit, Department of Cardiology, Nippon Medical School Hospital, Tokyo, Japan
| | - Naoki Sato
- Department of Cardiovascular Medicine, Kawaguchi Cardiovascular and Respiratory Hospital, Saitama, Japan
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
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Šiarnik P, Jurík M, Klobučníková K, Kollár B, Pirošová M, Malík M, Turčáni P, Sýkora M. Sleep apnea prediction in acute ischemic stroke (SLAPS score): a derivation study. Sleep Med 2020; 77:23-28. [PMID: 33302095 DOI: 10.1016/j.sleep.2020.11.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 11/15/2020] [Accepted: 11/18/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Despite its high prevalence and negative impact, sleep-disordered breathing (SDB) remain commonly underdiagnosed and undertreated in stroke subjects. Multiple stroke comorbidities and risk factors, including obesity, hypertension, diabetes mellitus, ischemic heart disease, atrial fibrillation, and heart failure (H.F.) have been associated with SDB. This study aimed to examine associations of clinical and demographic characteristics with moderate-to-severe SDB (msSDB) in stroke patients and to develop a predictive score. METHODS Consecutive patients with ischemic stroke were enrolled in an open, prospective study. SDB was assessed using standard polysomnography. Clinical and demographic characteristics, as well as findings from echocardiography, entered the analysis. Multivariate logistic regression models were used to examine the associations with msSDB. Based on the results, an original score to predict msSDB was proposed and tested. RESULTS 120 patients with acute ischemic stroke (mean age: 64.0 ± 12.2 years, median NIHSS: 4) were included. Body-mass index (BMI), wake-up stroke onset (WUS), and diastolic dysfunction were independently associated with msSDB. A score allocating 1 point for BMI≥25 kg/m2 and <30 kg/m2, 2 points for BMI≥30 kg/m2, 1 point for WUS and 1 point for diastolic dysfunction resulted in an area under the curve of 0.81 (95% CI 0.71-0.90, p<0.001), sensitivity 82.9%, specificity 71.9% to identify stroke patients with msSDB. CONCLUSIONS BMI, WUS, and diastolic dysfunction were associated with msSDB. A simple score might help to identify acute stroke patients with msSDB, who are usual candidates for positive airway pressure therapy.
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Affiliation(s)
- Pavel Šiarnik
- 1(st) Department of Neurology, Faculty of Medicine, Comenius University, Bratislava, Slovakia.
| | - Matúš Jurík
- 1(st) Department of Neurology, Faculty of Medicine, Comenius University, Bratislava, Slovakia.
| | - Katarína Klobučníková
- 1(st) Department of Neurology, Faculty of Medicine, Comenius University, Bratislava, Slovakia.
| | - Branislav Kollár
- 1(st) Department of Neurology, Faculty of Medicine, Comenius University, Bratislava, Slovakia.
| | - Margita Pirošová
- Department of Internal Medicine, Faculty of Medicine, Comenius University, Bratislava, Slovakia.
| | - Miroslav Malík
- Department of Radiology, Faculty of Medicine, Comenius University, Bratislava, Slovakia.
| | - Peter Turčáni
- 1(st) Department of Neurology, Faculty of Medicine, Comenius University, Bratislava, Slovakia.
| | - Marek Sýkora
- 1(st) Department of Neurology, Faculty of Medicine, Comenius University, Bratislava, Slovakia; Department of Neurology, St. John's Hospital, Medical Faculty, Sigmund Freud University Vienna, Austria.
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17
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Prehospital Treatment of Acute Pulmonary Edema with Intravenous Bolus and Infusion Nitroglycerin. Prehosp Disaster Med 2020; 35:663-668. [PMID: 33023684 DOI: 10.1017/s1049023x20001193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The study describes the implementation of a prehospital treatment algorithm that included intravenous (IV) bolus (IVB) nitroglycerin (NTG) followed by maintenance infusion for the treatment of acute pulmonary edema (APE) in a single, high-volume Emergency Medical Services (EMS) system. METHODS This is a retrospective chart review of patients who received IVB NTG for APE in a large EMS system in Minnesota and Wisconsin (USA). Inclusion criteria for treatment included a diagnosis of APE, systolic blood pressure ≥120mmHg, and oxygen saturation (SpO2) ≤93% following 800mcg of sublingual NTG. Patients received a 400mcg IVB of NTG, repeated every two minutes as needed, and subsequent infusion at 80mcg/min for transport times ≥10 minutes. RESULTS Forty-four patients were treated with IVB NTG. The median total bolus dose was 400mcg. Twenty patients were treated with NTG infusion following IVB NTG. The median infusion rate was 80mcg/min. For all patients, the initial median blood pressure was 191/113mmHg. Five minutes following IVB NTG, it was 160/94mmHg, and on arrival to the emergency department (ED) it was 152/90mmHg. Five minutes after the initial dose of IVB NTG, median SpO2 increased to 92% from an initial reading of 88% and was 94% at hospital arrival. One episode of transient hypotension occurred during EMS transport. CONCLUSION Patients treated with IVB NTG for APE had reduction in blood pressure and improvement in SpO2 compared to their original presentation. Prehospital treatment of APE with IVB appears to be feasible and safe. A randomized trial is needed to confirm these findings.
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18
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Effect of noninvasive ventilation on intubation risk in prehospital patients with acute cardiogenic pulmonary edema: a retrospective study. Eur J Emerg Med 2020; 27:54-58. [PMID: 31295150 PMCID: PMC6946102 DOI: 10.1097/mej.0000000000000616] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to assess the effect of prehospital noninvasive ventilation for acute cardiogenic pulmonary edema on endotracheal intubation rate and on ICU admission rate. METHODS We carried out a retrospective study on patients' prehospital files between 2007 and 2010 (control period), and between 2013 and 2016 (intervention period). Adult patients were included if a diagnosis of acute cardiogenic pulmonary edema was made by the prehospital physician. Exclusion criteria were a Glasgow coma scale score less than 9 or any other respiratory diagnosis. We analyzed the association between noninvasive ventilation implementation and endotracheal intubation or ICU admission with univariable and multivariable regression models. The primary outcome was prehospital endotracheal intubation rate. Secondary outcomes were admission to an ICU, prehospital intervention length, and 30-day mortality. RESULTS A total of 1491 patients were included. Noninvasive ventilation availability was associated with a significant decrease in endotracheal intubation rate (2.6% in the control versus 0.7% in the intervention period), with an adjusted odds ratio (OR) of 0.3 [95% confidence interval (CI), 0.1-0.7]. There was a decrease in ICU admissions (18.6% in the control versus 13.0% in the intervention period) with an adjusted OR of 0.6 (95% CI, 0.5-0.9). There was no significant change in 30-day mortality (11.2% in the control versus 11.0% in the intervention period, P = 0.901). CONCLUSION In our physician-staffed prehospital system, use of noninvasive ventilation for acute cardiogenic pulmonary edema decreased both endotracheal intubation and ICU admission rates.
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19
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Arrigo M, Jessup M, Mullens W, Reza N, Shah AM, Sliwa K, Mebazaa A. Acute heart failure. Nat Rev Dis Primers 2020; 6:16. [PMID: 32139695 PMCID: PMC7714436 DOI: 10.1038/s41572-020-0151-7] [Citation(s) in RCA: 215] [Impact Index Per Article: 53.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/28/2020] [Indexed: 12/11/2022]
Abstract
Acute heart failure (AHF) is a syndrome defined as the new onset (de novo heart failure (HF)) or worsening (acutely decompensated heart failure (ADHF)) of symptoms and signs of HF, mostly related to systemic congestion. In the presence of an underlying structural or functional cardiac dysfunction (whether chronic in ADHF or undiagnosed in de novo HF), one or more precipitating factors can induce AHF, although sometimes de novo HF can result directly from the onset of a new cardiac dysfunction, most frequently an acute coronary syndrome. Despite leading to similar clinical presentations, the underlying cardiac disease and precipitating factors may vary greatly and, therefore, the pathophysiology of AHF is highly heterogeneous. Left ventricular diastolic or systolic dysfunction results in increased preload and afterload, which in turn lead to pulmonary congestion. Fluid retention and redistribution result in systemic congestion, eventually causing organ dysfunction due to hypoperfusion. Current treatment of AHF is mostly symptomatic, centred on decongestive drugs, at best tailored according to the initial haemodynamic status with little regard to the underlying pathophysiological particularities. As a consequence, AHF is still associated with high mortality and hospital readmission rates. There is an unmet need for increased individualization of in-hospital management, including treatments targeting the causative factors, and continuation of treatment after hospital discharge to improve long-term outcomes.
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Affiliation(s)
- Mattia Arrigo
- Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Mariell Jessup
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Wilfried Mullens
- Ziekenhuis Oost Limburg, Genk, Belgium.,University of Hasselt, Hasselt, Belgium
| | - Nosheen Reza
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ajay M. Shah
- School of Cardiovascular Medicine & Sciences, King’s College London British Heart Foundation Centre, London, UK
| | - Karen Sliwa
- Hatter Institute for Cardiovascular Research in Africa, Faculty of Health Sciences, Department of Medicine and Cardiology, University of Cape Town, Cape Town, South Africa
| | - Alexandre Mebazaa
- Université de Paris, MASCOT, Inserm, Paris, France. .,Department of Anesthesia, Burn and Critical Care Medicine, AP-HP, Hôpital Lariboisière, Paris, France.
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20
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Lamboley L, Debax P, Courtiol G, Ricard C, Morvan C, Debaty G, Dubie E, Oberlin J, Savary D, Ageron FX, Belle L. Quality of acute heart failure treatment in France: Data from REseau Nord-Alpin des Urgences (RENAU). Ann Cardiol Angeiol (Paris) 2019; 68:285-292. [PMID: 31570158 DOI: 10.1016/j.ancard.2019.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 08/28/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Although mortality due to acute heart failure has decreased, its prevalence in France is still high. The aim of this study was to examine the quality of acute heart failure treatment in French emergency departments (EDs) with reference to subsequently published European Society of Cardiology (ESC) recommendations. METHODS The medical records of patients with acute pulmonary oedema (as a marker for acute heart failure) admitted to the EDs of 11 French hospitals in 2013 were reviewed retrospectively. RESULTS A total of 834 patients were included (median [interquartile range] age 84 [78-89] years; 48.6% male). Rates of compliance of initial management in 2013 to subsequently published 2015 recommendations were as follows: (1) thoracic ultrasound was performed in 17.3%; (2) loop diuretics were given in 75.9%; at a correct dose (among those for whom this was calculable) in 40.0% (3); intravenous nitrates were given in 21.7% of patients with systolic blood pressure>110mmHg; (4) non-invasive ventilation was initiated in 22.0% of patients with respiratory distress. Discharge summaries most often lacked a scheduled cardiologist follow-up (89.4%) and discharge patient weight (78.9%). CONCLUSIONS The early management of patients with acute pulmonary oedema (as a marker of acute heart failure) in France in 2013 was quite different to recommendations published in 2015. A programme to implement the new recommendations is in place, and a repeat evaluation will be conducted in 2017.
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Affiliation(s)
- L Lamboley
- Emergency department, hospital, Annecy, France
| | - P Debax
- Emergency department, university hospital of Grenoble-Alps, Grenoble, France
| | - G Courtiol
- Emergency department, hospital, Annecy, France
| | - C Ricard
- Reseau Nord-Alpin des urgences, hospital, Annecy, France
| | - C Morvan
- Reseau Nord-Alpin des urgences, hospital, Annecy, France
| | - G Debaty
- Emergency department, university hospital of Grenoble-Alps, Grenoble, France
| | - E Dubie
- Emergency department, hospital, Chambery, France
| | - J Oberlin
- Emergency department, university hospital of Grenoble-Alps, Grenoble, France
| | - D Savary
- Emergency department, hospital, Annecy, France
| | - F-X Ageron
- Emergency department, hospital, Annecy, France
| | - L Belle
- Reseau Nord-Alpin des urgences, hospital, Annecy, France; Cardiology department, hospital, Annecy, France.
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22
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Berbenetz N, Wang Y, Brown J, Godfrey C, Ahmad M, Vital FMR, Lambiase P, Banerjee A, Bakhai A, Chong M. Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary oedema. Cochrane Database Syst Rev 2019; 4:CD005351. [PMID: 30950507 PMCID: PMC6449889 DOI: 10.1002/14651858.cd005351.pub4] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Non-invasive positive pressure ventilation (NPPV) has been used to treat respiratory distress due to acute cardiogenic pulmonary oedema (ACPE). We performed a systematic review and meta-analysis update on NPPV for adults presenting with ACPE. OBJECTIVES To evaluate the safety and effectiveness of NPPV compared to standard medical care (SMC) for adults with ACPE. The primary outcome was hospital mortality. Important secondary outcomes were endotracheal intubation, treatment intolerance, hospital and intensive care unit length of stay, rates of acute myocardial infarction, and adverse event rates. SEARCH METHODS We searched CENTRAL (CRS Web, 20 September 2018), MEDLINE (Ovid, 1946 to 19 September 2018), Embase (Ovid, 1974 to 19 September 2018), CINAHL Plus (EBSCO, 1937 to 19 September 2018), LILACS, WHO ICTRP, and clinicaltrials.gov. We also reviewed reference lists of included studies. We applied no language restrictions. SELECTION CRITERIA We included blinded or unblinded randomised controlled trials in adults with ACPE. Participants had to be randomised to NPPV (continuous positive airway pressure (CPAP) or bilevel NPPV) plus standard medical care (SMC) compared with SMC alone. DATA COLLECTION AND ANALYSIS Two review authors independently screened and selected articles for inclusion. We extracted data with a standardised data collection form. We evaluated the risks of bias of each study using the Cochrane 'Risk of bias' tool. We assessed evidence quality for each outcome using the GRADE recommendations. MAIN RESULTS We included 24 studies (2664 participants) of adult participants (older than 18 years of age) with respiratory distress due to ACPE, not requiring immediate mechanical ventilation. People with ACPE presented either to an Emergency Department or were inpatients. ACPE treatment was provided in an intensive care or Emergency Department setting. There was a median follow-up of 13 days for hospital mortality, one day for endotracheal intubation, and three days for acute myocardial infarction. Compared with SMC, NPPV may reduce hospital mortality (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.51 to 0.82; participants = 2484; studies = 21; I2 = 6%; low quality of evidence) with a number needed to treat for an additional beneficial outcome (NNTB) of 17 (NNTB 12 to 32). NPPV probably reduces endotracheal intubation rates (RR 0.49, 95% CI 0.38 to 0.62; participants = 2449; studies = 20; I2 = 0%; moderate quality of evidence) with a NNTB of 13 (NNTB 11 to 18). There is probably little or no difference in acute myocardial infarction (AMI) incidence with NPPV compared to SMC for ACPE (RR 1.03, 95% CI 0.91 to 1.16; participants = 1313; studies = 5; I2 = 0%; moderate quality of evidence). We are uncertain as to whether NPPV increases hospital length of stay (mean difference (MD) -0.31 days, 95% CI -1.23 to 0.61; participants = 1714; studies = 11; I2 = 55%; very low quality of evidence). Adverse events were generally similar between NPPV and SMC groups, but evidence was of low quality. AUTHORS' CONCLUSIONS Our review provides support for continued clinical application of NPPV for ACPE, to improve outcomes such as hospital mortality and intubation rates. NPPV is a safe intervention with similar adverse event rates to SMC alone. Additional research is needed to determine if specific subgroups of people with ACPE have greater benefit of NPPV compared to SMC. Future research should explore the benefit of NPPV for ACPE patients with hypercapnia.
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Affiliation(s)
| | - Yongjun Wang
- Schulich School of Medicine & Dentistry, Western UniversityKresge Building, Rm. K1LondonONCanada
| | | | | | - Mahmood Ahmad
- Royal Free Hospital, Royal Free London NHS Foundation TrustCardiology DepartmentLondonUK
| | - Flávia MR Vital
- Cochrane Brazil Minas GeraisAv. Cristiano Ferreira Varella, 555MuriaéMinas GeraisBrazil36888‐233
| | - Pier Lambiase
- The Heart Hospital, University College London HospitalsCentre for Cardiology in the Young16‐18 Westmoreland Street,LondonUKW1G 8PH
| | - Amitava Banerjee
- University College LondonInstitute of Health Informatics ResearchLondonUK
| | - Ameet Bakhai
- Royal Free London NHS Foundation TrustBarnet General Hospital Cardiology DepartmentBarnet General HospitalThames House, Wellhouse LaneBarnetEnfieldUKEN5 3DJ
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23
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Comellini V, Pacilli AMG, Nava S. Benefits of non-invasive ventilation in acute hypercapnic respiratory failure. Respirology 2019; 24:308-317. [PMID: 30636373 DOI: 10.1111/resp.13469] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/18/2018] [Accepted: 12/09/2018] [Indexed: 02/02/2023]
Abstract
Non-invasive ventilation (NIV) with bilevel positive airway pressure is a non-invasive technique, which refers to the provision of ventilatory support through the patient's upper airway using a mask or similar device. This technique is successful in correcting hypoventilation. It has become widely accepted as the standard treatment for patients with hypercapnic respiratory failure (HRF). Since the 1980s, NIV has been used in intensive care units and, after initial anecdotal reports and larger series, a number of randomized trials have been conducted. Data from these trials have shown that NIV is a valuable treatment for HRF. This review aims to explore the principal areas in which NIV can be useful, focusing particularly on patients with acute HRF (AHRF). We will update the evidence base with the goal of supporting clinical practice. We provide a practical description of the main indications for NIV in AHRF and identify the group of patients with hypercapnic failure who will benefit most from the application of NIV.
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Affiliation(s)
- Vittoria Comellini
- Respiratory and Critical Care Unit, University Hospital St Orsola-Malpighi, Bologna, Italy
| | - Angela Maria Grazia Pacilli
- Department of Specialistic, Diagnostic and Experimental Medicine (DIMES), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Stefano Nava
- Respiratory and Critical Care Unit, University Hospital St Orsola-Malpighi, Bologna, Italy.,Department of Specialistic, Diagnostic and Experimental Medicine (DIMES), Alma Mater Studiorum University of Bologna, Bologna, Italy
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24
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Alqahtani JS, AlAhmari MD. Evidence based synthesis for prevention of noninvasive ventilation related facial pressure ulcers. Saudi Med J 2018; 39:443-452. [PMID: 29738002 PMCID: PMC6118171 DOI: 10.15537/smj.2018.5.22058] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The last 2 decades have seen a growing trend towards the use of noninvasive ventilation (NIV) therapy in the management of many conditions that cause acute respiratory failure. However, there is a serious side effect that results in using these devices; the development of facial skin pressure damage, specifically pressure ulcers. This skin damage has a considerable effect on patients’ quality of life, treatment adherence and patients’ comfort in addition to the therapy challenges of wound care. The aim of this clinical review is to discuss the different characteristics of NIV interfaces and to provide evidence based recommendations to facilitate the selection and application of such interfaces to reduce NIV interfaces related pressure ulcers.
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Affiliation(s)
- Jaber S Alqahtani
- Department of Respiratory Care, Prince Sultan Military College of Health Sciences, Dammam, Kingdom of Saudi Arabia. E-mail.
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25
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Bello G, De Santis P, Antonelli M. Non-invasive ventilation in cardiogenic pulmonary edema. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:355. [PMID: 30370282 DOI: 10.21037/atm.2018.04.39] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Cardiogenic pulmonary edema (CPE) is among the most common causes of acute respiratory failure (ARF) in the acute care setting and often requires ventilatory assistance. In patients with ARF due to CPE, use of non-invasive positive airway pressure can decrease the systemic venous return and the left ventricular (LV) afterload, thus reducing LV filling pressure and limiting pulmonary edema. In these patients, either non-invasive ventilation (NIV) or continuous positive airway pressure (CPAP) can improve vital signs and physiological parameters, decreasing the need for endotracheal intubation (ETI) and hospital mortality when compared to conventional oxygen therapy. Results on the use of NIV or CPAP in patients with CPE prior to hospitalization are not homogeneous among studies, hampering any conclusive recommendation regarding their role in the pre-hospital setting.
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Affiliation(s)
- Giuseppe Bello
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Paolo De Santis
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Massimo Antonelli
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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26
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Čerlinskaitė K, Javanainen T, Cinotti R, Mebazaa A. Acute Heart Failure Management. Korean Circ J 2018; 48:463-480. [PMID: 29856141 PMCID: PMC5986746 DOI: 10.4070/kcj.2018.0125] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 05/02/2018] [Indexed: 01/06/2023] Open
Abstract
Acute heart failure (AHF) is a life-threatening medical condition, where urgent diagnostic and treatment methods are of key importance. However, there are few evidence-based treatment methods. Interestingly, despite relatively similar ways of management of AHF throughout the globe, mid-term outcome in East Asia, including South Korea is more favorable than in Europe. Yet, most of the treatment methods are symptomatic. The cornerstone of AHF management is identifying precipitating factors and specific phenotype. Multidisciplinary approach is important in AHF, which can be caused or aggravated by both cardiac and non-cardiac causes. The main pathophysiological mechanism in AHF is congestion, both systemic and inside the organs (lung, kidney, or liver). Cardiac output is often preserved in AHF except in a few cases of advanced heart failure. This paper provides guidance on AHF management in a time-based approach. Treatment strategies, criteria for triage, admission to hospital and discharge are described.
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Affiliation(s)
- Kamilė Čerlinskaitė
- Department of Anesthesiology and Reanimation, Hôpital Lariboisière, Paris, France
- Department of Anesthesiology and Critical Care, Hôpitaux Universitaires Saint Louis-Lariboisiere, Assistance Publique des Hopitaux de Paris, Paris, France
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Tuija Javanainen
- Department of Anesthesiology and Reanimation, Hôpital Lariboisière, Paris, France
- Department of Anesthesiology and Critical Care, Hôpitaux Universitaires Saint Louis-Lariboisiere, Assistance Publique des Hopitaux de Paris, Paris, France
- Department of Cardiology, University of Helsinki, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Raphaël Cinotti
- Department of Anesthesiology and Reanimation, Hôpital Lariboisière, Paris, France
- Department of Anesthesiology and Critical Care, Hôpitaux Universitaires Saint Louis-Lariboisiere, Assistance Publique des Hopitaux de Paris, Paris, France
- Department of Anesthesia and Critical Care, University Hospital of Nantes, Nantes Cedex, France
| | - Alexandre Mebazaa
- Department of Anesthesiology and Reanimation, Hôpital Lariboisière, Paris, France
- Department of Anesthesiology and Critical Care, Hôpitaux Universitaires Saint Louis-Lariboisiere, Assistance Publique des Hopitaux de Paris, Paris, France
- University Paris Diderot, Paris, France.
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27
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Abstract
PURPOSE OF REVIEW The bidirectional relationships that have been demonstrated between heart failure (HF) and central sleep apnea (CSA) demand further exploration with respect to the implications that each condition has for the other. This review discusses the body of literature that has accumulated on these relationships and how CSA and its potential treatment may affect outcomes in patients with CSA. RECENT FINDINGS Obstructive sleep apnea (OSA) can exacerbate hypertension, type 2 diabetes, obesity, and atherosclerosis, which are known predicates of HF. Conversely, patients with HF more frequently exhibit OSA partly due to respiratory control system instability. These same mechanisms are responsible for the frequent association of HF with CSA with or without a Hunter-Cheyne-Stokes breathing (HCSB) pattern. Just as is the case with OSA, patients with HF complicated by CSA exhibit more severe cardiac dysfunction leading to increased mortality; the increase in severity of HF can in turn worsen the degree of sleep disordered breathing (SDB). Thus, a bidirectional relationship exists between HF and both phenotypes of SDB; moreover, an individual patient may exhibit a combination of these phenotypes. Both types of SDB remain significantly underdiagnosed in patients with HF and hence undertreated. Appropriate screening for, and treatment of, OSA is clearly a significant factor in the comprehensive management of HF, while the relevance of CSA remains controversial. Given the unexpected results of the Treatment of Sleep-Disordered Breathing with Predominant Central Sleep Apnea by Adaptive Servo Ventilation in Patients with Heart Failure trial, it is now of paramount importance that additional analysis of these data be expeditiously reported. It is also critical that ongoing and proposed prospective studies of this issue proceed without delay.
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28
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Masip J, Peacock WF, Price S, Cullen L, Martin-Sanchez FJ, Seferovic P, Maisel AS, Miro O, Filippatos G, Vrints C, Christ M, Cowie M, Platz E, McMurray J, DiSomma S, Zeymer U, Bueno H, Gale CP, Lettino M, Tavares M, Ruschitzka F, Mebazaa A, Harjola VP, Mueller C. Indications and practical approach to non-invasive ventilation in acute heart failure. Eur Heart J 2018; 39:17-25. [PMID: 29186485 PMCID: PMC6251669 DOI: 10.1093/eurheartj/ehx580] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 09/11/2017] [Accepted: 10/01/2017] [Indexed: 12/19/2022] Open
Abstract
In acute heart failure (AHF) syndromes significant respiratory failure (RF) is essentially seen in patients with acute cardiogenic pulmonary oedema (ACPE) or cardiogenic shock (CS). Non-invasive ventilation (NIV), the application of positive intrathoracic pressure through an interface, has shown to be useful in the treatment of moderate to severe RF in several scenarios. There are two main modalities of NIV: continuous positive airway pressure (CPAP) and pressure support ventilation (NIPSV) with positive end expiratory pressure. Appropriate equipment and experience is needed for NIPSV, whereas CPAP may be administered without a ventilator, not requiring special training. Both modalities have shown to be effective in ACPE, by a reduction of respiratory distress and the endotracheal intubation rate compared to conventional oxygen therapy, but the impact on mortality is less conclusive. Non-invasive ventilation is also indicated in patients with AHF associated to pulmonary disease and may be considered, after haemodynamic stabilization, in some patients with CS. There are no differences in the outcomes in the studies comparing both techniques, but CPAP is a simpler technique that may be preferred in low-equipped areas like the pre-hospital setting, while NIPSV may be preferable in patients with significant hypercapnia. The new modality 'high-flow nasal cannula' seems promising in cases of AHF with less severe RF. The correct selection of patients and interfaces, early application of the technique, the achievement of a good synchrony between patients and the ventilator avoiding excessive leakage, close monitoring, proactive management, and in some cases mild sedation, may warrant the success of the technique.
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Affiliation(s)
- Josep Masip
- Department of Intensive Care, Consorci Sanitari Integral, University of Barcelona, Jacint Verdaguer 90, Sant Joan Despí, ES-08970 Barcelona, Spain
- Department of Cardiology, Hospital Sanitas CIMA, Barcelona, Manuel Girona 33, ES 08034 Barcelona, Spain
| | - W Frank Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Susanna Price
- Departments of Cardiology and Intensive Care, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Louise Cullen
- Department of Emergency Medicine, Royal Brisbane and Women’s Hospital. Faculty of Health, Queensland University of Technology and University of Queensland, Brisbane, Australia
| | - F Javier Martin-Sanchez
- Department of Emergency, Hospital Clínico San Carlos. Instituto de Investigacıón Sanitaria (IdISSC), Madrid, Spain
| | - Petar Seferovic
- Department of Internal Medicine, Belgrade University School of Medicine and Heart Failure Centre, Belgrade University Medical Centre, Belgrade, Serbia
| | - Alan S Maisel
- Coronary Care Unit and Heart Failure Program, Department of Cardiology, VA San Diego, USA
| | - Oscar Miro
- Department of Emergency, Hospital Clínic, “Processes and Pathologies, Emergencies Research Group” IDIBAPS, University of Barcelona, Catalonia, Spain
| | - Gerasimos Filippatos
- Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Athens University Hospital Attikon, Athens, Greece
| | - Christiaan Vrints
- Faculty of Medicine and Health Sciences at University of Antwerp, Antwerp, Belgium
| | - Michael Christ
- Department of Emergency Medicine, Luzerner Katonsspital, Lucerne, Switzerland
| | - Martin Cowie
- Department of Cardiology, Imperial College London (Royal Brompton Hospital & Harefield Foundation Trust), London, UK
| | - Elke Platz
- Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - John McMurray
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Salvatore DiSomma
- Department of Emergency, Sant’Andrea Hospital. II Faculty of Medicine and Psychology, “LaSapienza”, Rome University, Rome, Italy
| | - Uwe Zeymer
- Institut für Herzinfarktforschung Ludwigshafen, Klinikum Ludwigshafen, Germany
| | - Hector Bueno
- Centro Nacional de Investigaciones Cardiovasculares, Department of Cardiology, Hospital 12 de Octubre, Madrid, Universidad Complutense de Madrid, Madrid, Spain
| | - Chris P Gale
- Department of Cardiology, York Teaching Hospital, Medical Research Council Bioinformatics Centre, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, York, UK
| | | | - Mucio Tavares
- Department of Emergency, Heart Institute (InCor), University of São Paulo Medical School, Brazil
| | - Frank Ruschitzka
- Department of Cardiology, Heart Failure Clinic and Transplantation, University Heart Centre Zurich, Zurich, Switzerland
| | - Alexandre Mebazaa
- Department of Anesthesiology and Critical Care, U942 Inserm, APHP Hôpitaux Universitaires Saint Louis Lariboisiére, Université Paris Diderot and Hospital Lariboisiére, Paris, France
| | - Veli-Pekka Harjola
- Department of Emergency Medicine and Services, Helsinki University, Helsinki University Hospital, Helsinki, Finland
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
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29
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Rochwerg B, Brochard L, Elliott MW, Hess D, Hill NS, Nava S, Navalesi P, Antonelli M, Brozek J, Conti G, Ferrer M, Guntupalli K, Jaber S, Keenan S, Mancebo J, Mehta S, Raoof S. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J 2017. [PMID: 28860265 DOI: 10.1183/13993003.02426–2016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Noninvasive mechanical ventilation (NIV) is widely used in the acute care setting for acute respiratory failure (ARF) across a variety of aetiologies. This document provides European Respiratory Society/American Thoracic Society recommendations for the clinical application of NIV based on the most current literature.The guideline committee was composed of clinicians, methodologists and experts in the field of NIV. The committee developed recommendations based on the GRADE (Grading, Recommendation, Assessment, Development and Evaluation) methodology for each actionable question. The GRADE Evidence to Decision framework in the guideline development tool was used to generate recommendations. A number of topics were addressed using technical summaries without recommendations and these are discussed in the supplementary material.This guideline committee developed recommendations for 11 actionable questions in a PICO (population-intervention-comparison-outcome) format, all addressing the use of NIV for various aetiologies of ARF. The specific conditions where recommendations were made include exacerbation of chronic obstructive pulmonary disease, cardiogenic pulmonary oedema, de novo hypoxaemic respiratory failure, immunocompromised patients, chest trauma, palliation, post-operative care, weaning and post-extubation.This document summarises the current state of knowledge regarding the role of NIV in ARF. Evidence-based recommendations provide guidance to relevant stakeholders.
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Affiliation(s)
- Bram Rochwerg
- Dept of Medicine, Dept of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Keenan Research Centre and Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Mark W Elliott
- Dept of Respiratory Medicine, St James's University Hospital, Leeds, UK
| | - Dean Hess
- Respiratory Care Dept, Massachusetts General Hospital and Dept of Anesthesia, Harvard Medical School, Boston, MA, USA
| | - Nicholas S Hill
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA, USA
| | - Stefano Nava
- Dept of Specialistic, Diagnostic and Experimental Medicine, Respiratory and Critical Care, Sant'Orsola Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Paolo Navalesi
- Anesthesia and Intensive Care, Dept of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Massimo Antonelli
- Dept of Anesthesiology and Intensive Care Medicine, Catholic University of Rome, A. Gemelli University Hospital, Rome, Italy
| | - Jan Brozek
- Dept of Medicine, Dept of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Giorgio Conti
- Dept of Anesthesiology and Intensive Care Medicine, Catholic University of Rome, A. Gemelli University Hospital, Rome, Italy
| | - Miquel Ferrer
- Dept of Pneumology, Respiratory Institute, Hospital Clinic, IDIBAPS, University of Barcelona and CIBERES, Barcelona, Spain
| | - Kalpalatha Guntupalli
- Depts of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Samir Jaber
- Dept of Critical Care Medicine and Anesthesiology (DAR B), Research Unit INSERM U1046, Saint Eloi University Hospital and Montpellier School of Medicine, Montpellier, France
| | - Sean Keenan
- Division of Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada.,Dept of Critical Care Medicine, Royal Columbian Hospital, New Westminster, BC, Canada
| | - Jordi Mancebo
- Servei de Medicina Intensiva, Hospital de Sant Pau, Barcelona, Spain
| | - Sangeeta Mehta
- Mount Sinai Hospital and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Suhail Raoof
- Pulmonary and Critical Care Medicine, Lenox Hill Hospital, New York, NY, USA.,Hofstra Northwell School of Medicine, Hempstead, NY, USA
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30
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Rochwerg B, Brochard L, Elliott MW, Hess D, Hill NS, Nava S, Navalesi P, Antonelli M, Brozek J, Conti G, Ferrer M, Guntupalli K, Jaber S, Keenan S, Mancebo J, Mehta S, Raoof S. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J 2017; 50:50/2/1602426. [PMID: 28860265 DOI: 10.1183/13993003.02426-2016] [Citation(s) in RCA: 710] [Impact Index Per Article: 101.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 06/15/2017] [Indexed: 12/13/2022]
Abstract
Noninvasive mechanical ventilation (NIV) is widely used in the acute care setting for acute respiratory failure (ARF) across a variety of aetiologies. This document provides European Respiratory Society/American Thoracic Society recommendations for the clinical application of NIV based on the most current literature.The guideline committee was composed of clinicians, methodologists and experts in the field of NIV. The committee developed recommendations based on the GRADE (Grading, Recommendation, Assessment, Development and Evaluation) methodology for each actionable question. The GRADE Evidence to Decision framework in the guideline development tool was used to generate recommendations. A number of topics were addressed using technical summaries without recommendations and these are discussed in the supplementary material.This guideline committee developed recommendations for 11 actionable questions in a PICO (population-intervention-comparison-outcome) format, all addressing the use of NIV for various aetiologies of ARF. The specific conditions where recommendations were made include exacerbation of chronic obstructive pulmonary disease, cardiogenic pulmonary oedema, de novo hypoxaemic respiratory failure, immunocompromised patients, chest trauma, palliation, post-operative care, weaning and post-extubation.This document summarises the current state of knowledge regarding the role of NIV in ARF. Evidence-based recommendations provide guidance to relevant stakeholders.
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Affiliation(s)
- Bram Rochwerg
- Dept of Medicine, Dept of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Keenan Research Centre and Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Mark W Elliott
- Dept of Respiratory Medicine, St James's University Hospital, Leeds, UK
| | - Dean Hess
- Respiratory Care Dept, Massachusetts General Hospital and Dept of Anesthesia, Harvard Medical School, Boston, MA, USA
| | - Nicholas S Hill
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA, USA
| | - Stefano Nava
- Dept of Specialistic, Diagnostic and Experimental Medicine, Respiratory and Critical Care, Sant'Orsola Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Paolo Navalesi
- Anesthesia and Intensive Care, Dept of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Massimo Antonelli
- Dept of Anesthesiology and Intensive Care Medicine, Catholic University of Rome, A. Gemelli University Hospital, Rome, Italy
| | - Jan Brozek
- Dept of Medicine, Dept of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Giorgio Conti
- Dept of Anesthesiology and Intensive Care Medicine, Catholic University of Rome, A. Gemelli University Hospital, Rome, Italy
| | - Miquel Ferrer
- Dept of Pneumology, Respiratory Institute, Hospital Clinic, IDIBAPS, University of Barcelona and CIBERES, Barcelona, Spain
| | - Kalpalatha Guntupalli
- Depts of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Samir Jaber
- Dept of Critical Care Medicine and Anesthesiology (DAR B), Research Unit INSERM U1046, Saint Eloi University Hospital and Montpellier School of Medicine, Montpellier, France
| | - Sean Keenan
- Division of Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada.,Dept of Critical Care Medicine, Royal Columbian Hospital, New Westminster, BC, Canada
| | - Jordi Mancebo
- Servei de Medicina Intensiva, Hospital de Sant Pau, Barcelona, Spain
| | - Sangeeta Mehta
- Mount Sinai Hospital and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Suhail Raoof
- Pulmonary and Critical Care Medicine, Lenox Hill Hospital, New York, NY, USA.,Hofstra Northwell School of Medicine, Hempstead, NY, USA
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31
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Noninvasive ventilation for acute lung injury a meta-analysis of randomized controlled trials. Heart Lung 2017; 45:249-57. [PMID: 27154849 DOI: 10.1016/j.hrtlng.2016.02.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 01/19/2016] [Accepted: 02/14/2016] [Indexed: 11/23/2022]
Abstract
PURPOSE To compare the effect of noninvasive ventilation (NIV) and standard oxygen therapy on treating acute lung injury (ALI). METHODS A search on PubMed, Embase, Springer, Cochrane Central Register of Controlled Trials and Clinical Trials was carried out up to Nov 2015 for randomized controlled trials (RCTs) with NIV as cases and standard oxygen therapy as controls. Risk ratios and weight mean difference were used for estimation. RESULTS This meta-analysis included seventeen RCTs. Results showed NIV significantly reduced the intubation rate, length of ICU stay and hospital mortality. The length of hospital stay and ICU mortality were not different. High heterogeneity was found across the studies of intubation rate. The types of acute respiratory failure might be a source of heterogeneity. CONCLUSION Our results suggest that NIV is effective for ALI in reducing the intubation rate, hospital mortality and length of ICU stay than the standard oxygen therapy.
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Long-Term Mortality of Emergency Medical Services Patients. Ann Emerg Med 2017; 70:366-373.e3. [PMID: 28347554 DOI: 10.1016/j.annemergmed.2016.12.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 12/08/2016] [Accepted: 12/13/2016] [Indexed: 01/17/2023]
Abstract
STUDY OBJECTIVE Emergency medical services (EMS) provides out-of-hospital care to patients with life-threatening conditions, but the long-term outcomes of EMS patients are unknown. We seek to determine the long-term mortality of EMS patients in Denmark. METHODS We analyzed linked EMS, hospital, and vital status data from 3 of 5 geographic regions in Denmark. We included events from July 1, 2011, to December 31, 2012. We classified EMS events according to primary dispatch category (unconsciousness/cardiac arrest, accidents/trauma, chest pain, dyspnea, neurologic symptoms, and other EMS patients). The primary outcome was 1-year mortality adjusted for age, sex, and Charlson comorbidity index. RESULTS Among 142,125 EMS events, primary dispatch categories were unconsciousness or cardiac arrest 5,563 (3.9%), accidents or trauma 40,784 (28.7%), chest pain 20,945 (14.7%), dyspnea 9,607 (6.8%), neurologic symptoms 17,804 (12.5%), and other EMS patients 47,422 (33.4%). One-year mortality rates were unconscious or cardiac arrest 54.7% (95% confidence interval [CI] 53.4% to 56.1%), accidents or trauma 7.8 (95% CI 7.5% to 8.1%), chest pain 8.5% (95% CI 8.1% to 9.0%), dyspnea 27.7% (95% CI 26.7% to 28.7%), neurologic symptoms 14.1% (95% CI 13.6% to 14.7%), and other EMS patients 11.1% (95% CI 10.8% to 11.4%). Compared with other EMS conditions, adjusted 1-year mortality was higher in unconsciousness or cardiac arrest (risk ratio [RR] 2.6; 95% CI 2.5 to 2.7), dyspnea (RR 1.5; 95% CI 1.4 to 1.5), and in neurologic symptoms (RR 1.1; 95% CI 1.0 to 1.1), but lower in chest pain (RR 0.6; 95% CI 0.6 to 0.7) and accidents or trauma (RR 0.8; 95% CI 0.8 to 0.8). CONCLUSION EMS patients with unconsciousness or cardiac arrest, dyspnea, and neurologic symptoms are at highest risk of long-term mortality. Our results suggest a potential for outcome improvement in these patients.
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The impact of emergency medical services in acute heart failure. Int J Cardiol 2017; 232:222-226. [PMID: 28096039 DOI: 10.1016/j.ijcard.2017.01.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 12/30/2016] [Accepted: 01/03/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Real-life data on the role of emergency medical services (EMS) in acute heart failure (AHF) are scarce. Our aim was to describe prehospital treatment of AHF and to compare patients using EMS with self-presented, non-EMS patients. METHODS Data were collected retrospectively from three university hospitals in Helsinki metropolitan area between July 1, 2012 and July 31, 2013. According to the use of EMS, patients were divided into EMS and non-EMS groups. RESULTS The study included 873 AHF patients. One hundred were (11.5%) EMS and 773 (88.5%) non-EMS. EMS patients more often had comorbidities. Initial heart rate (HR) and peripheral oxygen saturation (SpO2) differed between EMS and non-EMS patients; mean HR 89.2 (SD 22.5) vs. 83.7 (21.5)/min (p=0.02) and SpO2 90.3 (8.6) vs. 92.9 (6.6)% (p=0.01). However, on presentation to ED EMS patients' vital signs were similar to non-EMS patients'. On presentation to ED 46.0% were normotensive and 68.2% "warm and wet". Thirty-four percentage of EMS patients received prehospital medication. In-hospital mortality was 6.0% and 7.1% (p=0.84) and length of stay (LOS) 7.7 (7.0) and 8.5 (7.9) days (p=0.36) in EMS and non-EMS groups. CONCLUSION The use of EMS and administration of prehospital medication was low. EMS patients had initially worse HR and SpO2 than non-EMS patients. However, EMS patients' signs improved and were similar on presentation to ED. There were no differences in in-hospital mortality and LOS. This underscores the need for equal attention to any AHF patient independent of the arrival mode.
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Beneficial effects of rapid introduction of adaptive servo-ventilation in the emergency room in patients with acute cardiogenic pulmonary edema. J Cardiol 2017; 69:308-313. [DOI: 10.1016/j.jjcc.2016.05.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 05/09/2016] [Accepted: 05/25/2016] [Indexed: 01/08/2023]
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Hongisto M, Lassus J, Tarvasmaki T, Sionis A, Tolppanen H, Lindholm MG, Banaszewski M, Parissis J, Spinar J, Silva-Cardoso J, Carubelli V, Di Somma S, Masip J, Harjola VP. Use of noninvasive and invasive mechanical ventilation in cardiogenic shock: A prospective multicenter study. Int J Cardiol 2016; 230:191-197. [PMID: 28043661 DOI: 10.1016/j.ijcard.2016.12.175] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 12/22/2016] [Accepted: 12/25/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Despite scarce data, invasive mechanical ventilation (MV) is widely recommended over non-invasive ventilation (NIV) for ventilatory support in cardiogenic shock (CS). We assessed the real-life use of different ventilation strategies in CS and their influence on outcome focusing on the use of NIV and MV. METHODS 219 CS patients were categorized by the maximum intensity of ventilatory support they needed during the first 24h into MV (n=137; 63%) , NIV (n=26; 12%), and supplementary oxygen (n=56; 26%) groups. We compared the clinical characteristics and 90-day outcome between the MV and the NIV groups. RESULTS Mean age was 67years, 74% were men. The MV and NIV groups did not differ in age, medical history, etiology of CS, PaO2/FiO2 ratio, baseline hemodynamics or LVEF. MV patients predominantly presented with hypoperfusion, with more severe metabolic acidosis, higher lactate levels and greater need for vasoactive drugs, whereas NIV patients tended to be more often congestive. 90-day outcome was significantly worse in the MV group (50% vs. 27%), but after propensity score adjustment, mortality was equal in both groups. Confusion, prior CABG, ACS etiology, higher lactate level, and lower baseline PaO2 were independent predictors of mortality, whereas ventilation strategy did not have any influence on outcome. CONCLUSIONS Although MV is generally recommended mode of ventilatory support in CS, a fair number of patients were successfully treated with NIV. Moreover, ventilation strategy was not associated with outcome. Thus, NIV seems a safe option for properly chosen CS patients.
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Affiliation(s)
- Mari Hongisto
- Emergency Medicine, University of Helsinki, Department of Emergency Care, Helsinki University Hospital, Helsinki, Finland.
| | - Johan Lassus
- Helsinki University Hospital, Heart and Lung Center, Division of Cardiology, Helsinki, Finland
| | - Tuukka Tarvasmaki
- Emergency Medicine, University of Helsinki, Department of Emergency Care, Helsinki University Hospital, Helsinki, Finland
| | - Alessandro Sionis
- Intensive Cardiac Care Unit, Cardiology Department, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau) Barcelona, Spain
| | - Heli Tolppanen
- Helsinki University Hospital, Heart and Lung Center, Division of Cardiology, Helsinki, Finland
| | - Matias Greve Lindholm
- Rigshospitalet, Copenhagen University Hospital, Intensive Cardiac Care Unit, Copenhagen, Denmark
| | - Marek Banaszewski
- Institute of Cardiology, Intensive Cardiac Therapy Clinic, Warsaw, Poland
| | - John Parissis
- Attikon University Hospital, Heart Failure Clinic and Secondary Cardiology Department, Athens, Greece
| | - Jindrich Spinar
- University Hospital Brno, Department of Internal Medicine and Cardiology, Brno, Czech Republic
| | - Jose Silva-Cardoso
- University of Porto, CINTESIS, Department of Cardiology, Porto Medical School, São João Hospital Center, Porto, Portugal
| | - Valentina Carubelli
- Division of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University and Civil Hospital of Brescia, Italy
| | - Salvatore Di Somma
- Department of Medical Sciences and Translational Medicine, University of Rome Sapienza, Emergency Medicine Sant'Andrea Hospital, Rome, Italy
| | - Josep Masip
- University of Barcelona, Hospital Sant Joan Despi Moisès Broggi, Critical Care Department, Consorci Sanitari Integral, Barcelona, Spain
| | - Veli-Pekka Harjola
- Emergency Medicine, University of Helsinki, Department of Emergency Care, Helsinki University Hospital, Helsinki, Finland
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Nielsen VML, Madsen J, Aasen A, Toft-Petersen AP, Lübcke K, Rasmussen BS, Christensen EF. Prehospital treatment with continuous positive airway pressure in patients with acute respiratory failure: a regional observational study. Scand J Trauma Resusc Emerg Med 2016; 24:121. [PMID: 27724976 PMCID: PMC5057371 DOI: 10.1186/s13049-016-0315-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 10/04/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with acute respiratory failure are at risk of deterioration during prehospital transport. Ventilatory support with continuous positive airway pressure (CPAP) can be initiated in the prehospital setting. The objective of the study is to evaluate adherence to treatment and effectiveness of CPAP as an addition to standard care. METHODS In North Denmark Region, patients with acute respiratory failure, whom paramedics assessed as suffering from acute cardiopulmonary oedema, acute exacerbation of chronic obstructive pulmonary disease or asthma were treated with CPAP using 100 % O2 from 1 March 2014 to 3 May 2015. Adherence to treatment was evaluated by number of adverse events and discontinuation of treatment. Intensive care admissions and mortality were reported in this cohort. Effectiveness was evaluated by changes in peripheral oxygen saturation (SpO2) and respiratory rate during transport and compared to a historical control (non-CPAP) group treated with standard care only. Values were compared by hypothesis testing and linear modelling of SpO2 on arrival at scene and ΔSpO2 stratified according to treatment group. RESULTS In fourteen months, 171 patients were treated with CPAP (mean treatment time 35 ± 18 min). Adverse events were reported in 15 patients (9 %), hereof six discontinued CPAP due to hypotension, nausea or worsening dyspnoea. One serious adverse event was reported, a suspected pneumothorax treated adequately by an anaesthesiologist called from a mobile emergency care unit. Among CPAP patients, 45 (27 %) were admitted to an intensive care unit and 24 (14 %) died before hospital discharge. The non-CPAP group consisted of 739 patients. From arrival at scene to arrival at hospital, CPAP patients had a larger increase in SpO2 than non-CPAP patients (87 to 96 % versus 92 to 96 %, p < 0.01) and a larger decrease in respiratory rate (32 to 25 versus 28 to 24 breaths/min, p < 0.01). In a linear model, CPAP was superior to non-CPAP in patients with initial SpO2 ≤90 % (p < 0.05). One CPAP patient (0.6 %) and eight non-CPAP patients (1.1 %) were intubated in the prehospital setting. DISCUSSION The study design reflects the daily prehospital working environment including long transport timesand paramedics educated in treating symptoms of acute respiratory failure, rather than treating one specific diagnosis. The study population was included consecutively and few patients were lost to follow-up. However, the study was too small to allow assessment of any effect of prehospital CPAP on mortality, nor could the effectiveness in specific disease conditions be examined. CONCLUSIONS In an emergency medical service including physician backup, adherence to CPAP treatment administered by paramedics was high and treatment was effective in patients with acute respiratory failure.
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Affiliation(s)
- Vibe Maria Laden Nielsen
- Department of Anaesthesiology and Intensive Care Medicine, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jacob Madsen
- Department of Anaesthesiology and Intensive Care Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Anette Aasen
- Department of Anaesthesiology and Intensive Care Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Anne Pernille Toft-Petersen
- Department of Anaesthesiology and Intensive Care Medicine, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Kenneth Lübcke
- Prehospital Emergency Medical Services, North Denmark Region, Aalborg, Denmark
| | - Bodil Steen Rasmussen
- Department of Anaesthesiology and Intensive Care Medicine, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Erika Frischknecht Christensen
- Department of Anaesthesiology and Intensive Care Medicine, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Prehospital Emergency Medical Services, North Denmark Region, Aalborg, Denmark
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Pirracchio R, Carone M, Rigon MR, Caruana E, Mebazaa A, Chevret S. Propensity score estimators for the average treatment effect and the average treatment effect on the treated may yield very different estimates. Stat Methods Med Res 2016; 25:1938-1954. [DOI: 10.1177/0962280213507034] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective Propensity score matching is typically used to estimate the average treatment effect for the treated while inverse probability of treatment weighting aims at estimating the population average treatment effect. We illustrate how different estimands can result in very different conclusions. Study design We applied the two propensity score methods to assess the effect of continuous positive airway pressure on mortality in patients hospitalized for acute heart failure. We used Monte Carlo simulations to investigate the important differences in the two estimates. Results Continuous positive airway pressure application increased hospital mortality overall, but no continuous positive airway pressure effect was found on the treated. Potential reasons were (1) violation of the positivity assumption; (2) treatment effect was not uniform across the distribution of the propensity score. From simulations, we concluded that positivity bias was of limited magnitude and did not explain the large differences in the point estimates. However, when treatment effect varies according to the propensity score (E[Y(1)–Y(0)|g(X)] is not constant, Y being the outcome and g(X) the propensity score), propensity score matching ATT estimate could strongly differ from the inverse probability of treatment weighting-average treatment effect estimate. We show that this empirical result is supported by theory. Conclusion Although both approaches are recommended as valid methods for causal inference, propensity score-matching for ATT and inverse probability of treatment weighting for average treatment effect yield substantially different estimates of treatment effect. The choice of the estimand should drive the choice of the method.
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Affiliation(s)
- R Pirracchio
- Department of Biostatistics, INSERM UMR-S717; Hôpital Saint Louis, AP-HP; Université Paris Diderot, Sorbonne Paris Cité; Paris, France
- Department of Anesthesiology & Critical Care, Hôpital Européen Georges Pompidou, AP-HP; Université Paris Descartes, Sorbonne Paris Cité; Paris, France
- Division of Biostatistics, School of Public Health, University of California at Berkeley, Berkeley, USA
| | - M Carone
- Division of Biostatistics, School of Public Health, University of California at Berkeley, Berkeley, USA
| | - M Resche Rigon
- Department of Biostatistics, INSERM UMR-S717; Hôpital Saint Louis, AP-HP; Université Paris Diderot, Sorbonne Paris Cité; Paris, France
| | - E Caruana
- Department of Biostatistics, INSERM UMR-S717; Hôpital Saint Louis, AP-HP; Université Paris Diderot, Sorbonne Paris Cité; Paris, France
| | - A Mebazaa
- Department of Anesthesiology & Critical Care, INSERM UMR-S942; Hôpital Lariboisière, AP-HP; Université Paris Diderot, Sorbonne Paris Cité; Paris, France
| | - S Chevret
- Department of Biostatistics, INSERM UMR-S717; Hôpital Saint Louis, AP-HP; Université Paris Diderot, Sorbonne Paris Cité; Paris, France
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Piroddi IMG, Barlascini C, Esquinas A, Braido F, Banfi P, Nicolini A. Non-invasive mechanical ventilation in elderly patients: A narrative review. Geriatr Gerontol Int 2016; 17:689-696. [PMID: 27215767 DOI: 10.1111/ggi.12810] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 03/17/2016] [Accepted: 03/25/2016] [Indexed: 10/21/2022]
Abstract
The treatment of acute respiratory failure with non-invasive ventilation (NIV) as a first-line therapy is increasingly common in intensive care units. The reduced invasiveness of NIV leads to better outcomes than endotracheal intubation in carefully selected groups of patients. Furthermore, the use of NIV as a palliative treatment for respiratory failure and dyspnea has become increasingly common. NIV also has an impact on the use of "do not intubate" orders. In the present narrative review, we explore the use and outcome of NIV in elderly patients. To accomplish this, we reviewed the most recent available medical literature. Geriatr Gerontol Int 2017; 17: 689-696.
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Affiliation(s)
| | - Cornelius Barlascini
- Hygiene and Health Medicine Unit Hospital of Sestri Levante, Sestri Levante, Italy
| | | | - Fulvio Braido
- Allergy and Respiratory Diseases Unit Department IRCSS AOU San Martino- IST, Genova, Italy
| | - Paolo Banfi
- Pulmonary Rehabilitation Fondazione Don Carlo Gnocchi, Milan, Italy
| | - Antonello Nicolini
- Respiratory Diseases Unit Hospital of Sestri Levante, Sestri Levante, Italy
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Pandor A, Thokala P, Goodacre S, Poku E, Stevens JW, Ren S, Cantrell A, Perkins GD, Ward M, Penn-Ashman J. Pre-hospital non-invasive ventilation for acute respiratory failure: a systematic review and cost-effectiveness evaluation. Health Technol Assess 2016; 19:v-vi, 1-102. [PMID: 26102313 DOI: 10.3310/hta19420] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Non-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. OBJECTIVES We 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 SOURCES Fourteen 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 METHODS We 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. RESULTS The 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. LIMITATIONS The 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. CONCLUSIONS Pre-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 REGISTRATION The study is registered as PROSPERO CRD42012002933. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Abdullah Pandor
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Praveen Thokala
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Edith Poku
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - John W Stevens
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Shijie Ren
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Anna Cantrell
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Matt Ward
- West Midlands Ambulance Service NHS Foundation Trust, West Midlands, UK
| | - Jerry Penn-Ashman
- West Midlands Ambulance Service NHS Foundation Trust, West Midlands, UK
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Mebazaa A, Yilmaz MB, Levy P, Ponikowski P, Peacock WF, Laribi S, Ristic AD, Lambrinou E, Masip J, Riley JP, McDonagh T, Mueller C, deFilippi C, Harjola VP, Thiele H, Piepoli MF, Metra M, Maggioni A, McMurray J, Dickstein K, Damman K, Seferovic PM, Ruschitzka F, Leite-Moreira AF, Bellou A, Anker SD, Filippatos G. Recommendations on pre-hospital & early hospital management of acute heart failure: a consensus paper from the Heart Failure Association of the European Society of Cardiology, the European Society of Emergency Medicine and the Society of Academic Emergenc. Eur J Heart Fail 2015; 17:544-58. [DOI: 10.1002/ejhf.289] [Citation(s) in RCA: 275] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 01/09/2015] [Accepted: 03/02/2015] [Indexed: 01/30/2023] Open
Affiliation(s)
- Alexandre Mebazaa
- University Paris Diderot, Sorbonne Paris Cité; APHP; Lariboisière Saint Louis University Hospitals; Paris France
| | - M. Birhan Yilmaz
- Department of Cardiology; Cumhuriyet University Faculty of Medicine; Sivas 58140 Turkey
| | - Phillip Levy
- Department of Emergency Medicine and Cardiovascular Research Institute; Wayne State University School of Medicine; Detroit USA
| | - Piotr Ponikowski
- Wroclaw Medical University; 4th Military Hospital, Weigla 5 Wroclaw 50-981 Poland
| | - W. Frank Peacock
- Baylor College of Medicine; Ben Taub General Hospital; 1504 Taub Loop, Houston TX 77030 USA
| | | | - Arsen D. Ristic
- Department of Cardiology; Clinical Center of Serbia and Belgrade University School of Medicine; Belgrade Serbia
| | - Ekaterini Lambrinou
- Nursing Department, Cyprus University of Technology; School of Health Sciences; Limassol Cyprus
| | - Josep Masip
- Consorci Sanitari Integral, Hospital Sant Joan DespiMoise's Broggi and Hospital General Hospitalet; University of Barcelona; Barcelona Spain
| | | | | | | | - Christopher deFilippi
- School of Medicine, Division of Cardiovascular Medicine; University of Maryland; Baltimore MD USA
| | - Veli-Pekka Harjola
- Emergency Medicine; University of Helsinki, Helsinki University Hospital; Helsinki Finland
| | - Holger Thiele
- University of Luebeck, University Hospital of Schleswig-Holstein; Medical Clinic II Luebeck Germany
| | - Massimo F. Piepoli
- Heart Failure Unit, Cardiac Dept.; Guglielmo da Saliceto Hospital; AUSL Piacenza Italy
| | - Marco Metra
- Cardiology, The Department of Medical and Surgical Specialties, Radiological Sciences and Public Health; University of Brescia; Brescia Italy
| | | | - John McMurray
- BHF Cardiovascular Research Centre; University of Glasgow; 126 University Place Glasgow UK
| | | | - Kevin Damman
- University of Groningen, University Medical Center Groningen; Groningen The Netherlands
| | - Petar M. Seferovic
- Medical Faculty; University of Belgrade; Belgrade Serbia
- Department of Cardiology; University Medical Center; Belgrade Serbia
| | - Frank Ruschitzka
- Department of Cardiology; University Heart Center; Rämistrasse 100 Zurich 8091 Switzerland
| | - Adelino F. Leite-Moreira
- Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine; University of Porto; Porto Portugal
- Department of Cardiothoracic Surgery; Centro Hospitalar Sao Joao; Porto Portugal
| | - Abdelouahab Bellou
- Harvard Medical School and Emergency Medicine Department of Beth Israel Deaconess Medical Center; Boston USA
- Faculty of Medicine; University Rennes 1; Rennes France
| | - Stefan D. Anker
- Division of Applied Cachexia Research; Department of Cardiology, Charite' Medical School; Berlin Germany
- Division of Innovative Clinical Trials, Department of Cardiology; University Medical Centre Göttingen (UMG); Göttingen Germany
| | - Gerasimos Filippatos
- Department of Cardiology; Attikon University Hospital, University of Athens Medical School; Athens Greece
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Factors Associated with Failure of Non-invasive Positive Pressure Ventilation in a Critical Care Helicopter Emergency Medical Service. Prehosp Disaster Med 2015; 30:239-43. [PMID: 25723378 DOI: 10.1017/s1049023x15000199] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Non-invasive positive pressure ventilation (NIPPV) is used to treat severe acute respiratory distress. Prehospital NIPPV has been associated with a reduction in both in-hospital mortality and the need for invasive ventilation. HYPOTHESIS/PROBLEM The authors of this study examined factors associated with NIPPV failure and evaluated the impact of NIPPV on scene times in a critical care helicopter Emergency Medical Service (HEMS). Non-invasive positive pressure ventilation failure was defined as the need for airway intervention or alternative means of ventilatory support. METHODS A retrospective chart review of consecutive patients where NIPPV was completed in a critical care HEMS was conducted. Factors associated with NIPPV failure in univariate analyses and from published literature were included in a multivariable, logistic regression model. RESULTS From a total of 44 patients, NIPPV failed in 14 (32%); a Glasgow Coma Scale (GCS)<15 at HEMS arrival was associated independently with NIPPV failure (adjusted odds ratio 13.9; 95% CI, 2.4-80.3; P=.003). Mean scene times were significantly longer in patients who failed NIPPV when compared with patients in whom NIPPV was successful (95 minutes vs 51 minutes; 39.4 minutes longer; 95% CI, 16.2-62.5; P=.001). CONCLUSION Patients with a decreased level of consciousness were more likely to fail NIPPV. Furthermore, patients who failed NIPPV had significantly longer scene times. The benefits of NIPPV should be balanced against risks of long scene times by HEMS providers. Knowing risk factors of NIPPV failure could assist HEMS providers to make the safest decision for patients on whether to initiate NIPPV or proceed directly to endotracheal intubation prior to transport.
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Aguilar SA. Reply to "statistical errors in a recent article in the journal". J Emerg Med 2015; 48:219-221. [PMID: 25456775 DOI: 10.1016/j.jemermed.2014.09.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 09/30/2014] [Indexed: 06/04/2023]
Affiliation(s)
- Steve A Aguilar
- Department of Emergency Medicine, University of California, San Diego, San Diego, CA
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Abstract
Pulmonary oedema (PO) is a common manifestation of acute heart failure (AHF) and is associated with a high-acuity presentation and with poor in-hospital outcomes. The clinical picture of PO is dominated by signs of pulmonary congestion, and its pathogenesis has been attributed predominantly to an imbalance in Starling forces across the alveolar-capillary barrier. However, recent studies have demonstrated that PO formation and resolution is critically regulated by active endothelial and alveolar signalling. PO represents a medical emergency and treatment should be individually tailored to the urgency of the presentation and acute haemodynamic characteristics. Although, the majority of patients admitted with PO rapidly improve as result of conventional intravenous (IV) therapies, treatment of PO remains largely opinion based as there is a general lack of good evidence to guide therapy. Furthermore, none of these therapies showed simultaneous benefit for symptomatic relief, haemodynamic improvement, increased survival and end-organ protection. Future research is required to develop innovative pharmacotherapies capable of relieving congestion while simultaneously preventing end-organ damage.
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Affiliation(s)
- Ovidiu Chioncel
- Institute of Emergency for Cardiovascular Diseases 'Prof. C.C. Iliescu', University of Medicine and Pharmacy Carol Davila, Bucuresti, Romania
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University, Nashville, Tennessee, US
| | | | - Mihai Gheorghiade
- Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, US
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Bakke SA, Botker MT, Riddervold IS, Kirkegaard H, Christensen EF. Continuous positive airway pressure and noninvasive ventilation in prehospital treatment of patients with acute respiratory failure: a systematic review of controlled studies. Scand J Trauma Resusc Emerg Med 2014; 22:69. [PMID: 25416493 PMCID: PMC4251922 DOI: 10.1186/s13049-014-0069-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 11/05/2014] [Indexed: 11/24/2022] Open
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.
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Affiliation(s)
- Skule A Bakke
- Department of Anesthesiology, Hospital of Southern Jutland, Southern Jutland, Denmark.
| | - Morten T Botker
- Prehospital Research Department, Prehospital Emergency Medical Services, Central Denmark Region, Denmark.
| | - Ingunn S Riddervold
- Prehospital Research Department, Prehospital Emergency Medical Services, Central Denmark Region, Denmark.
| | - Hans Kirkegaard
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark.
| | - Erika F Christensen
- Prehospital Research Department, Prehospital Emergency Medical Services, Central Denmark Region, Denmark.
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Goodacre S, Stevens JW, Pandor A, Poku E, Ren S, Cantrell A, Bounes V, Mas A, Payen D, Petrie D, Roessler MS, Weitz G, Ducros L, Plaisance P. Prehospital noninvasive ventilation for acute respiratory failure: systematic review, network meta-analysis, and individual patient data meta-analysis. Acad Emerg Med 2014; 21:960-70. [PMID: 25269576 DOI: 10.1111/acem.12466] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2014] [Revised: 05/08/2014] [Accepted: 05/13/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVES This meta-analysis aimed to determine the effectiveness of prehospital continuous positive airway pressure (CPAP) or bilevel inspiratory positive airway pressure (BiPAP) in acute respiratory failure. METHODS Fourteen electronic databases and research registers were searched from inception to August 2013. Randomized or quasi-randomized controlled trials that reported mortality or intubation rate for prehospital CPAP or BiPAP were selected and compared to a relevant comparator in patients with acute respiratory failure. An aggregate data network meta-analysis was used to jointly estimate intervention effects relative to standard care. A network meta-analysis using a mixture of individual patient-level data and aggregate data was carried out to assess potential treatment effect modifiers. RESULTS Eight randomized and two quasi-randomized controlled trials (six CPAP, four BiPAP, sample sizes 23 to 207) were identified. The aggregate data network meta-analysis 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 to 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) was uncertain. The network meta-analysis using individual patient-level data and aggregate data suggested that sex was a modifier of the effect of treatment on mortality. CONCLUSIONS Prehospital CPAP can reduce mortality and intubation rates compared to standard care, while the effectiveness of prehospital BiPAP is uncertain.
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Affiliation(s)
- Steve Goodacre
- The School of Health and Related Research (ScHARR) University of Sheffield Sheffield UK
| | - John W. Stevens
- The School of Health and Related Research (ScHARR) University of Sheffield Sheffield UK
| | - Abdullah Pandor
- The School of Health and Related Research (ScHARR) University of Sheffield Sheffield UK
| | - Edith Poku
- The School of Health and Related Research (ScHARR) University of Sheffield Sheffield UK
| | - Shijie Ren
- The School of Health and Related Research (ScHARR) University of Sheffield Sheffield UK
| | - Anna Cantrell
- The School of Health and Related Research (ScHARR) University of Sheffield Sheffield UK
| | - Vincent Bounes
- The Department of Emergency Medicine Toulouse University Hospital Toulouse France
| | - Arantxa Mas
- The Intensive Care Department Hospital de Sant Joan Despí Moisès Broggi Barcelona Spain
| | - Didier Payen
- The Department of Anaesthesiology and Critical Care Lariboisière Hospital Paris France
| | - David Petrie
- The Department of Emergency Medicine Dalhousie University Nova Scotia Canada
| | - Markus Soeren Roessler
- The Department of Anaesthesiology Emergency and Intensive Care Medicine Georg‐August‐University Goettingen Germany
| | - Gunther Weitz
- The University Hospital of Schleswig‐Holstein Lübeck Germany
| | - Laurent Ducros
- The Department of Anaesthesiology and Critical Care Lariboisière Hospital Paris France
| | - Patrick Plaisance
- The Department of Emergency Medicine Lariboisière University Hospital Paris France
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Abstract
After the institution of positive-pressure ventilation, the use of noninvasive ventilation (NIV) through an interface substantially increased. The first technique was continuous positive airway pressure; but, after the introduction of pressure support ventilation at the end of the 20th century, this became the main modality. Both techniques, and some others that have been recently introduced and which integrate some technological innovations, have extensively demonstrated a faster improvement of acute respiratory failure in different patient populations, avoiding endotracheal intubation and facilitating the release of conventional invasive mechanical ventilation. In acute settings, NIV is currently the first-line treatment for moderate-to-severe chronic obstructive pulmonary disease exacerbation as well as for acute cardiogenic pulmonary edema and should be considered in immunocompromised patients with acute respiratory insufficiency, in difficult weaning, and in the prevention of postextubation failure. Alternatively, it can also be used in the postoperative period and in cases of pneumonia and asthma or as a palliative treatment. NIV is currently used in a wide range of acute settings, such as critical care and emergency departments, hospital wards, palliative or pediatric units, and in pre-hospital care. It is also used as a home care therapy in patients with chronic pulmonary or sleep disorders. The appropriate selection of patients and the adaptation to the technique are the keys to success. This review essentially analyzes the evidence of benefits of NIV in different populations with acute respiratory failure and describes the main modalities, new devices, and some practical aspects of the use of this technique.
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Affiliation(s)
- Arantxa Mas
- Critical Care Department, Consorci Sanitari Integral (CSI), Hospital Sant Joan Despí Moisès Broggi and Hospital General de l’Hospitalet, University of Barcelona, Barcelona, Spain
| | - Josep Masip
- Critical Care Department, Consorci Sanitari Integral (CSI), Hospital Sant Joan Despí Moisès Broggi and Hospital General de l’Hospitalet, University of Barcelona, Barcelona, Spain
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[Prehospital non-invasive ventilation in Germany: results of a nationwide survey of ground-based emergency medical services]. Anaesthesist 2014; 63:217-24. [PMID: 24569935 DOI: 10.1007/s00101-014-2300-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Revised: 01/20/2014] [Accepted: 01/22/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND OBJECTIVES Non-invasive ventilation (NIV) is an evidence-based treatment of acute respiratory failure and can be helpful to reduce morbidity and mortality. In Germany national S3 guidelines for inhospital use of NIV based on a large number of clinical trials were published in 2008; however, only limited data for prehospital non-invasive ventilation (pNIV) and hence no recommendations for prehospital use exist so far. AIM In order to create a database for pNIV in Germany a nationwide survey was conducted to explore the status quo for the years 2005-2008 and to survey expected future developments including disposability, acceptance and frequency of pNIV. MATERIAL AND METHODS A questionnaire on the use of pNIV was developed and distributed to 270 heads of medical emergency services in Germany. RESULTS Of the 270 questionnaires distributed 142 could be evaluated (52 %). The pNIV was rated as a reasonable treatment option in 91 % of the respondents but was available in only 54 out of the 142 responding emergency medical services (38 %). Continuous positive airway pressure (98 %) and biphasic positive airway pressure (22 %) were the predominantly used ventilation modes. Indications for pNIV use were acute cardiogenic pulmonary edema (96 %), acute exacerbation of chronic obstructive pulmonary disease (89 %), asthma (32 %) and pneumonia (28 %). Adverse events were reported for panic (20 ± 17%) and non-threatening heart rhythm disorders (8 ± 5%), the rate of secondary intubation was low (reduction from 20 % to 10 %) and comparable to data from inhospital treatment. CONCLUSION Prehospital NIV in Germany was used by only one third of all respondents by the end of 2008. Based on the clinical data a growing application for pNIV is expected. Controlled prehospital studies are needed to enunciate evidence-based recommendations for pNIV.
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Laribi S, Aouba A, Nikolaou M, Lassus J, Cohen-Solal A, Plaisance P, Pavillon G, Jois P, Fonarow GC, Jougla E, Mebazaa A. Trends in death attributed to heart failure over the past two decades in Europe. Eur J Heart Fail 2014; 14:234-9. [DOI: 10.1093/eurjhf/hfr182] [Citation(s) in RCA: 108] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
- Said Laribi
- INSERM UMR-S 942, Hôpital Lariboisière; Paris France
- Paris Diderot University, Sorbonne Paris Cité; France
- AP-HP, Department of Emergency Medicine; Hôpital Lariboisière; Paris France
- The GREAT network ( http://www.greatnetwork.org )
| | - Albertine Aouba
- Center of Epidemiology for Medical Causes of Death (INSERM, CépiDc, Kremlin-Bicêtre); France
| | - Maria Nikolaou
- INSERM UMR-S 942, Hôpital Lariboisière; Paris France
- The GREAT network ( http://www.greatnetwork.org )
| | - Johan Lassus
- INSERM UMR-S 942, Hôpital Lariboisière; Paris France
- The GREAT network ( http://www.greatnetwork.org )
| | - Alain Cohen-Solal
- INSERM UMR-S 942, Hôpital Lariboisière; Paris France
- Paris Diderot University, Sorbonne Paris Cité; France
- The GREAT network ( http://www.greatnetwork.org )
| | - Patrick Plaisance
- Paris Diderot University, Sorbonne Paris Cité; France
- AP-HP, Department of Emergency Medicine; Hôpital Lariboisière; Paris France
- The GREAT network ( http://www.greatnetwork.org )
| | - Gérard Pavillon
- Center of Epidemiology for Medical Causes of Death (INSERM, CépiDc, Kremlin-Bicêtre); France
| | - Preeti Jois
- Department of Emergency Medicine; University of Florida; Gainesville FL USA
| | - Gregg C. Fonarow
- Department of Medicine; University of California-Los Angeles Medical Center; Los Angeles CA USA
| | - Eric Jougla
- Center of Epidemiology for Medical Causes of Death (INSERM, CépiDc, Kremlin-Bicêtre); France
| | - Alexandre Mebazaa
- INSERM UMR-S 942, Hôpital Lariboisière; Paris France
- Paris Diderot University, Sorbonne Paris Cité; France
- AP-HP, Department of Anesthesiology and Critical Care; Hôpital Lariboisière; Paris France
- The GREAT network ( http://www.greatnetwork.org )
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Mal S, McLeod S, Iansavichene A, Dukelow A, Lewell M. Effect of out-of-hospital noninvasive positive-pressure support ventilation in adult patients with severe respiratory distress: a systematic review and meta-analysis. Ann Emerg Med 2013; 63:600-607.e1. [PMID: 24342819 DOI: 10.1016/j.annemergmed.2013.11.013] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Revised: 11/05/2013] [Accepted: 11/15/2013] [Indexed: 11/30/2022]
Abstract
STUDY OBJECTIVE Noninvasive positive-pressure ventilation (NIPPV) is increasingly being used by emergency medical services (EMS) for treatment of patients in respiratory distress. The primary objective of this systematic review is to determine whether out-of-hospital NIPPV for treatment of adults with severe respiratory distress reduces inhospital mortality compared with "standard" therapy. Secondary objectives are to examine the need for invasive ventilation, hospital and ICU length of stay, and complications. METHODS Electronic searches of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing and Allied Health Literature were conducted and reference lists of relevant articles hand searched. Randomized controlled trials comparing out-of-hospital NIPPV with standard therapy in adults (aged ≥16 years) with severe respiratory distress published in English were included. Two reviewers independently screened abstracts, assessed quality of the studies, and extracted data. Data were pooled with random-effects models and reported as risk ratios (RRs) with 95% confidence intervals (CIs) and number needed to treat (NNT). RESULTS Seven randomized controlled trials were included, with a combined total of 632 patients; 313 in the standard therapy group and 319 in the NIPPV group. In patients treated with NIPPV, the pooled estimate showed a reduction in both inhospital mortality (RR 0.58; 95% CI 0.35 to 0.95; NNT=18) and need for invasive ventilation (RR 0.37; 95% CI 0.24 to 0.58; NNT=8). There was no difference in ICU or hospital length of stay. CONCLUSION Out-of-hospital administration of NIPPV appears to be an effective therapy for adult patients with severe respiratory distress.
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Affiliation(s)
- Sameer Mal
- Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada; London Health Sciences Centre, London, Ontario, Canada.
| | - Shelley McLeod
- Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada; London Health Sciences Centre, London, Ontario, Canada
| | | | - Adam Dukelow
- Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada; London Health Sciences Centre, London, Ontario, Canada
| | - Michael Lewell
- Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada; London Health Sciences Centre, London, Ontario, Canada
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Pirracchio R, Resche Rigon M, Mebazaa A, Zannad F, Alla F, Chevret S. Continuous positive airway pressure (CPAP) may not reduce short-term mortality in cardiogenic pulmonary edema: a propensity-based analysis. J Card Fail 2013; 19:108-16. [PMID: 23384636 DOI: 10.1016/j.cardfail.2012.12.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Revised: 12/18/2012] [Accepted: 12/21/2012] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Continuous positive airway pressure (CPAP) improves patients' condition in case of cardiogenic pulmonary edema (CPE). However, the impact of CPAP on short-term mortality remains a matter of debate. We aimed at estimating the effect of CPAP on short-term mortality in patients treated for a CPE. METHODS AND RESULTS We pooled the data from the Acute Heart Failure Global Registry of Standard Treatment and the Etude Francaise l'Innsuficiens Cardiaque Aigue observational cohorts to compare the estimations of the effect on short-term mortality of CPAP, before and after propensity score (PS) matching. A total of 2286 patients with a cardiogenic pulmonary edema were included in the analysis, of whom 321 (14%) received CPAP. Of these, 314 could be matched to a control patient (matched population: n = 628) and were included in the PS analysis. In naive analysis, CPAP application influenced neither short-term mortality (HR: 1.03, 95% CI: 0.73-1.46; P = .86) nor the need for tracheal intubation (OR: 1.04, 95% CI: 0.78-1.40; P = .78). After PS matching, CPAP was associated with a reduction in the need for tracheal intubation (OR: 0.56, 95% CI: 0.37-0.84; P = .005) but it did not reduce short-term mortality (HR: 0.77, 95% CI: 0.47-1.26; P = .30). CONCLUSIONS Despite a reduction in the need for tracheal intubation, CPAP application may not reduce short-term mortality in patients suffering from cardiogenic pulmonary edema.
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Affiliation(s)
- Romain Pirracchio
- Department of Biostatistics, Hôpital Saint Louis, Diderot, Paris, France.
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