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Prehospital continuous positive airway pressure ventilation in ACPO: part 2

02 April 2011
Other
02 April 2011
Volume 3 · Issue 4

Abstract

Acute cardiogenic pulmonary oedema (ACPO) is a common medical emergency facing UK paramedics. While swift management can delay progression of ACPO, a significant portion of patients spiral into deteriorating respiratory and cardiac function, leading to respiratory failure requiring endotracheal intubation (ETI). Continuous pulmonary airway pressure (CPAP) is increasingly being adopted into treatment regimens for ACPO in hospital. This is the second part of a paper seeking to critique the literature surrounding CPAP. Part one found how CPAP can provide early improvement in respiratory distress, metabolic abnormalities and need to ETI in hospital, yet these are not transferred into improved survival (Rees, 2011). Adherence and maximisation of medical therapy within JRCALC, and future potential of intravenous nitrates should also be explored by paramedics wishing to introduce CPAP into their practice. Methods: A comprehensive literature search of MEDLINE and CINAHL from 2000 to November 2010 was conducted using ‘CPAP’ as a subject heading combined with the subheadings: ‘pulmonary oedema’, ‘pulmonary edema’ ‘ACPO’, ‘heart failure’ ‘pre hospital’ and ‘paramedic’ as key words. A second search was conducted using ‘non invasive ventilation’ as a subject heading along all subheadings above. Results: A total of 253 papers were retrieved. These were manually scanned for relevance and eligibility, leaving a total of 53 papers for review. Given the relative scarcity in prehospital care literature all articles were reviewed, with nine finally selected for inclusion. No high quality UK prehospital studies were found. Application of CPAP resulted in significant improvements in physiological variables, need to ETI and relief of breathlessness. Despite these benefits, they are not transferred into improved mortality. Conclusion: The use of CPAP patients in ACPO can provide early improvement in respiratory distress, metabolic abnormalities and need to ETI in hospital. However, these are yet to be robustly transferred into improved survival. Despite this, many UK paramedics currently have limited options in supporting ventilation for ACPO. Adoption of CPAP into UK paramedic practice may offer options of a non–invasive means of supporting ventilation prior to ETI, with the potential of improving mortality by intervening early in ACPO. However, the limited number of quality prehospital studies presents many questions over its potential. Quality UK based studies are urgently needed.

This is the second part in a series of two articles seeking to critique the potential of continuous positive pressure ventilation (CPAP) devices for acute cardiogenic pulmonary oedema (ACPO) (Figure 1). Part one focused on the in hospital literature—it revealed how the pathogenesis of acute heart failure leading to ACPO, when recognized, offers scope for paramedic intervention to reduce the spiral of deteriorating respiratory and cardiac function.

Adherence to current JRCALC guidelines offers optimum management. Despite this, when medical intervention has been exhausted, application of CPAP is increasingly advocated—as studies show, improved physiological variables, reduced need of endotracheal intubation (ETI), and palliation of breathlessness.

However, confounding factors such as variance in the standard of medical treatments, severity of illness and setting limit the ability to attribute observed benefits to its application. A more recent study (Grey et al, 2009) addressed many of these issues, and despite finding improvements in physiological variables and palliation of breathlessness, improved survival did not follow.

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Acute cardiogenic pulmonary odedema (ACPO)
Continuous positive pressure ventilation (CPAP)
Paramedic
Prehospital