Prehospital continuous positive airway pressure ventilation in ACPO: part 2

Nigel Rees
Saturday, April 2, 2011

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.

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