Feasibility Study of the Use of Bilevel Positive Airway Pressure for Respiratory Support in the Emergency Department,☆☆,,★★,

Presented at the American College of Emergency Physicians research forum, San Francisco, California, February 1995.
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Abstract

Study objective: To determine the feasibility of bilevel positive airway pressure (BiPAP) support for acute respiratory distress (ARD) in the emergency department. Methods: A convenience sample of patients in ARD as a result of any nontraumatic cause was recruited for a prospective, noncontrolled clinical trial in the ED of an urban tertiary care teaching hospital. Hemodynamically unstable patients and those requiring immediate endotracheal intubation were excluded. After an initial arterial blood gas (AGB) analysis was obtained, the patient was placed on BiPAP (Bi-PAP S/T noninvasive ventilator; Respironics, Incorporated) by nose mask or face mask to provide noninvasive pressure support at 5 cm H2O. Settings were titrated to patient tolerance and satisfactory pulse oximetry. After at least 30 minutes on a stable setting, arterial blood gases were remeasured. The cause of respiratory distress, vital signs, assessment of need for intubation, arterial blood gas results, and patient disposition were recorded. Success of noninvasive support was defined as the presence of (1) improvement in ABG parameters, (2) clinical improvement and decrease in evident dyspnea, and (3) avoidance of endotracheal intubation and mechanical ventilation. Results: Fifty patients were studied. Causes of ARD included acute congestive heart failure (CHF; n=16), exacerbation of chronic obstructive pulmonary disease (COPD; n=9), mixed COPD/CHF (n=3), pneumonia (n=10), status asthmaticus (n=6), and other causes of acute respiratory failure (eg, stroke, overdose; n=6). Noninvasive management was successful in 43 patients (86%), with patients in all etiologic categories being equally likely to respond favorably to therapy. All patients were admitted to the hospital, but 52.5% of those who ordinarily would have required ICU beds were admitted to lower (and less costly) levels of care. Three patients were eventually intubated, all after admission to the ICU on BiPAP. Two patients did not tolerate BiPAP, and two others were considered ED treatment failures but were not intubated because of advance directives. Conclusion: As has been reported from other critical care settings, use of BiPAP is feasible and has potential utility in the management of ARD in the ED. [Pollack CV Jr, Torres MT, Alexander L: Feasibility study of the use of bilevel positive airway pressure for respiratory support in the emergency department. Ann Emerg Med February 1996;27:189-192.]

Section snippets

INTRODUCTION

There are growing clinical and fiscal pressures to avoid endotracheal intubation (ETI) and mechanical ventilation (MV) whenever feasible. In postanesthesia recovery units, critical care units, and in-home use, noninvasive bilevel positive airway pressure (BiPAP) support of spontaneous ventilation by face mask has conclusively been demonstrated to help physicians avoid ETI/MV in a variety of clinical settings.1, 2, 3, 4, 5 The ability to support noninvasively some emergency department patients

MATERIALS AND METHODS

Any patient who presented to our ED during the 8-month study period with ARD of any nontraumatic cause and who was hemodynamically stable with a patent airway was considered eligible for the protocol. Patients deemed to require immediate ETI for treatment of apnea or maintenance of airway protection were excluded. Because strict parameters for inclusion could not be developed, consistency of eligibility determination was ensured by having one of the authors (CP or MT) evaluate each potential

RESULTS

Fifty patients were enrolled in the study during an 8-month period. The causes of ARD in this population included acute CHF (n=16), exacerbation chronic obstructive pulmonary disease (COPD; n=9), mixed COPD/CHF (n=3), pneumonia (n=10), status asthmaticus (n=6), and other causes of acute respiratory failure (eg, cerebrovascular accident, overdose; n=6). Final IPAP settings ranged from 9 to 22 cm H2O, and EPAP from 3 to 9 cm H2O. ABG data and BiPAP settings are presented by cause of ARD in the

DISCUSSION

Advantages of noninvasive ventilation include avoidance of the risks, complications, and expense of ETI/MV; greater patient comfort; reduced need for sedation; lower risk of nosocomial infections; and preservation of speech, swallowing, and normal airway defense mechanisms. Disadvantages include sacrifice of the definitive control of airway and ventilation afforded by ETI/MV; the need for patient cooperation; impaired access to the airway for suctioning; facial skin pressure stress; and

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From the Departments of Emergency Medicine* and Respiratory Therapy, Maricopa Medical Center, Phoenix, Arizona.

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This study was supported by the loan of a BiPAP S/T noninvasive ventilatory by Respironics, Incorporated.

Dr Pollack serves on the Speakers Bureau of Respironics Inc.

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Address for reprints: Charles V Pollack Jr, MA, MD, PO Box 37936, Phoenix, Arizona 85069-7936, 602-267-5418, Fax 602-331-0716, E-mail [email protected]

Reprint no. 47/1/69973

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