The Science Journal of the American Association for Respiratory Care

2007 OPEN FORUM Abstracts


NON-INVASIVE VENTILATION (NPPV) IS PART OF THE “STANDARD OF CARE ” FOR THE TREATMENT OF ACUTE RESPIRATORY FAILURE (ARF) IN AN EMERGENCY DEPARTMENT; RESPIRATORY CARE DEPARTMENT CONSIDERATIONS.

J. B. Scott1, J. L. Cappiello, J. J. Thalman, N. R. MacIntyre


Background: NPPV in ARF from COPD and CHF exacerbations is an accepted therapy. Recent literature has discussed its potential use in other ARF causing pathologies. NPPV has been reviewed in patients suffering from status asthmaticus, pneumonia, for preoxygenation prior to intubation, and the hypercapnic coma patient, (Diaz, Chest 2005 Mar). Due to evidence and the availability of resources, NPPV has greatly increased in our ED. Because NPPV has a potential impact on RCD staff allocation, we sought to evaluate if NPPV is a “standard of care” treatment in ARF. Our setting is a tertiary care center ED that sees 60,000 patients a year.

Method: ED core team maintained a database of patients treated with NPPV who presented in ARF. ARF was defined as RR >28, pulse oximetry <92% on room air, dyspnea, and the inability to speak >3 words. On presentation to the ED, the physician and the RCP evaluated the patient for appropriateness of therapy. NPPV was initiated 20 minutes on arrival for all cases.

Results: A one year period, 67 patients, 1.8pts/week, met criteria. Mean NPPV time was 3.2 hours, 33 patients (49%) were admitted to the ICU, and 6 patients (8%) required intubation. DISCUSSION: NPPV in the setting of ARF has a great impact on respiratory care. As support for NPPV evolves with scientific evidence, the potential for this therapy increases. Critical care support is resource consuming and demanding of advanced practice skills. Our weekly rate of NPPV use, 1.8 pts/week is 5.8 hours of critical care time. Our respiratory care department's NPPV standards for ARF include airway management support, ventilator management, bronchodilator therapy, arterial blood gas sampling and/or indwelling arterial catheter insertions, pulse oximetry, non-invasive capnography, and continuing physician interaction. NPPV support is protocol driven allowing the RCP to make necessary adjustments as the patients’ condition changes. These cases are dynamic and require uninterrupted practitioner attention.

Conclusion:
Our ED considers NPPV necessary and part of the “standard of care” to treat ARF. Practitioner time for NPPV cases significantly impacts their workload. Staff allocation is adjusted per departmental guidelines for mechanically ventilated patients. The success of this therapy has a significant impact on our departments’ staff. As NPPV becomes a more widely accepted first line therapy, other institutions may need to review their staffing practice.