2002 OPEN FORUM Abstracts
of Continuous Positive Airway Pressure for
Congestive Heart Failure/ Pulmonary Edema: A Prospective
Treatment, Retrospective Control Study.
David Pavlakovich RRT, Dennis Hastings RRT, Russell K. Miller MD FACEP, Susan Keeney MD, John Monahan EMT-P, Craig Gray EMT-P. Pavlakovich, Hastings, Miller, and Keeney are associated with the University of Texas Medical Branch, Galveston, Texas. Miller, Monahan, and Gray are associated with Galveston EMS.
Background: Acute respiratory failure (ARF) secondary to congestive heart failure/cardiogenic pulmonary edema (CHF) is a life threatening emergency that accounts for a significant number of pre-hospital intubations by EMS personnel. This, in turn, leads to a significant number of intensive care admissions and can certainly account for a longer length of stay. Full face mask and nasal continuous positive airway pressure (CPAP) have been used in the hospital setting for many years, with great success, to avoid intubation of patients suffering from ARF secondary to CHF. EMS providers, however, have not had this option. Therefore our research questions were simple. By providing nasal CPAP as an option to EMS personnel can we make an impact on the intubation rate (in the field) of patients with congestive heart failure/pulmonary edema? Can we make an impact on the intensive care admission rate and length of stay for patients with congestive heart failure/pulmonary edema?
Method: We chose to make the study design a ?prospective treatment, retrospective control? and started using CPAP on September 1, 1997 and collected data until May 31, 1998 (what is considered to be the ?CHF season?). We limited the study to adult patients suffering from ARF secondary to CHF/pulmonary edema. The control period was September 1, 1996 - May 31, 1997. We set up a system that consisted of a Down?s flow generator (Vital Signs), CPAP/BiPAP tubing, Briggs adaptor (?T? piece), corrugated tubing, adjustable PEEP valve (Bird/LDS PEEP Flow), and a nasal CPAP/BiPAP mask (Healthdyne). The equipment is kept in a kit that is easily carried to the patient. The DFG was connected to the 50 PSI outlet of the oxygen tank used by EMS. Once the field diagnosis of CHF/pulmonary edema was made the Galveston EMS (GEMS) personnel would gauge the level of distress. If the distress was significant enough to warrant intubation then nasal CPAP was applied at 10 cm H2O pressure. If relief was not achieved in a few minutes then the level could be increased to 15 cm H2O before calling Medical Control for further orders. Also part of the CHF protocol is the use of nitroglycerine, furosemide, enalapril, and other measures to decrease the blood pressure. GEMS then transported the patients via ambulance to the University of Texas Medical Branch Emergency Department where supportive care was continued.
Results: GEMS responded to 54 patients suffering from ARF secondary to CHF who met criteria for intubation. Of those 54, 4 required immediate intubation. Fifty were placed on CPAP, and of that fifty, four failed CPAP and required intubation. ICU admission went from 100% to 48% and the average hospital stay decreased from 14.8 days to 8 days.
Conclusions: CPAP has been shown in the hospital to be an effective alternative to endotracheal intubation for patients suffering from ARF secondary to CHF. By taking this same technique into the pre-hospital setting, it has shown to be effective there as well. This, in turn has shown to have a significant impact in the rate of ICU admission and length of stay for patients suffering from CHF.