Selected Topics: Prehospital Care
Prehospital Use of Continuous Positive Airway Pressure for Acute Severe Congestive Heart Failure

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Abstract

Background

The utility of continuous positive airway pressure (CPAP) in the in-hospital treatment of congestive heart failure (CHF) is well established. Its exact role is less clear in the prehospital arena.

Objective

To describe the prehospital use of CPAP for patients presenting with acute severe heart failure in a large Emergency Medical Services system in New Jersey.

Methods

Retrospective review of prehospital charts from January 1, 2005 to December 31, 2006 of patients treated for acute CHF. Inclusion criteria for eligibility for CPAP mask use were: respiratory rate > 25 breaths/min, labored and shallow breathing, bilateral rales, history of CHF, intact mental status, and prehospital clinical diagnosis of CHF. Data collected included demographics, vital signs, oxygen saturation (SaO2), need for endotracheal intubation (ETI), and complications.

Results

There were 1306 charts reviewed; 387 patients met inclusion criteria. Of the 387, 149 patients had placement of CPAP (38.5%). The prehospital treatment times were (CPAP = 30 min; non-CPAP = 31 min; p < 0.01). The increase in SaO2 for the CPAP group (9%) vs. the non-CPAP group (5%) was statistically significant (p < 0.01). Systolic blood pressure (BP) reduction (CPAP [27.1 mm Hg], non-CPAP [19.9 mm Hg], p < 0.01), diastolic BP reduction (CPAP [14.1 mm Hg], non-CPAP [7.4 mm Hg], p < 0.01), heart rate reduction (CPAP [17.2 beats/min], non-CPAP [9.6 beats/min], p < 0.01), respiratory rate reduction (CPAP [5.63], non-CPAP [4.09], p < 0.01), and ETI reduction (CPAP [2.6%], non-CPAP [5.46%], p < 0.01), all were statistically significant. Adjunctive CHF treatments were similar between the groups.

Conclusion

The use of CPAP for eligible patients with acute severe CHF seems to be feasible and beneficial. Large-scale randomized prospective prehospital studies are needed to validate these results.

Introduction

In the United States, approximately 1 million patients per year are treated by paramedics for acute congestive heart failure (CHF). The associated morbidity and mortality are significant, as is the overall cost on the health care system. The most optimal prehospital management protocol of these patients is not clear and remains a work in progress. Prehospital management of acute CHF and cardiogenic pulmonary edema has historically centered on the use of oxygen, nitrates, diuretics, and morphine. Recent advances in non-invasive ventilation and its use in the management of acute CHF in the inpatient population have proven to be beneficial 1, 2. However, health care delivery in the prehospital arena has its unique challenges relating to paramedic expertise and training, as well as environmental challenges. Whether the same benefit can be derived in this setting is not clear. Through this retrospective study, we seek to review the prehospital treatment of cardiogenic pulmonary edema and severe congestive heart failure to better understand the potential role of continuous positive airway pressure (CPAP) in this group of patients and whether any benefits might be derived.

Section snippets

The Emergency Medical Services System

The Monmouth Ocean Hospital Service Corporation (MONOC) is the largest Emergency Medical Services (EMS) provider in the state of New Jersey. This system provides EMS services to an estimated 4.3 million people over a 1200-square-mile coverage area. The setting is both urban and suburban. Patients are treated and transported to over 40 different area hospitals, of which 15 are directly affiliated with this system. MONOC evaluates nearly 50,000 Advanced Life Support (ALS) patients per year. The

Results

During the study period from January 1, 2005 to December 31, 2006, a total of 1306 medical records were identified and reviewed. All patients were treated for acute CHF. Upon analysis, 387 patients met criteria for presumed severe CHF requiring CPAP application as per protocol. Only 149 (38.5%) patients received CPAP. Table 1 and Figure 1 summarize the data obtained for all patients.

The lack of CPAP application in those patients who qualified was in large part secondary to paramedic lack of

Discussion

Most prospective, randomized, controlled trials have shown that non-invasive ventilation seems to be efficacious in acute cardiogenic pulmonary edema and hypoxemic respiratory failure, as well as in patients with chronic obstructive pulmonary disease 3, 4, 5, 6, 7, 8, 9, 10, 11. However, studies documenting such benefits were done in large part on hospitalized patients in the setting of the ED or the intensive care unit. In the past few years, however, data began to emerge regarding its use in

Conclusion

CPAP can be safely utilized in the prehospital setting for the treatment of patients with acute CHF. Its use may be beneficial for improving hemodynamic parameters and oxygenation. In addition, prehospital use of CPAP may decrease the need for endotracheal intubation. Future prospective studies are warranted to validate these beneficial effects of CPAP in prehospital patients with acute CHF.

Article Summary

1. Why is this topic important?

  1. If proven effective, the use of continuous positive airway pressure (CPAP) in the prehospital setting may

References (20)

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