EMS transports for difficulty breathing: is there a potential role for CPAP in the prehospital setting?
Mask-applied continuous positive airway pressure (CPAP) has been shown to reduce morbidity among patients with acute respiratory distress in the setting of cardiogenic pulmonary edema. OBJECTIVE: To determine a minimum percentage of patients transported by ALS for difficulty breathing who could potentially benefit from a pre-hospital trial of CPAP. METHODS: Paramedic run sheets were collected from consecutive, adult, ALS transports for a chief complaint of difficulty breathing over a 6 week period in a large urban EMS system. Demographic information, medical history, vital signs, clinical assessments, and transport times were abstracted into a database by trained reviewers. Strict criteria for CPAP were defined in advance as "acute respiratory distress," meaning (1) respiratory rate > 25 and (2) labored or shallow breathing, and "presumed cardiogenic pulmonary edema," meaning (3) a prior history of heart disease and (4) presence of bilateral rales on exam. RESULTS: Data from 240 consecutive run sheets were compiled. Median patient age was 66 years old, with females outnumbering males 168 to 81. A total of 15 spontaneously breathing patients met all 4 criteria for CPAP. Four of these patients were either hypotensive (SBP < 90) or had potential for airway compromise (i.e., obtundation), making CPAP inadvisable. Among the 11 remaining patients (4.4% of all transports for difficult breathing), median transport time was 20 minutes (range 14-31 minutes). CONCLUSIONS: Using very strict criteria, a small but not significant percentage of patients are optimal candidates for a prehospital trial of CPAP. Transport times would appear to justify this type of intervention. A prospective study is currently under way to test the feasibility of administering CPAP to such patients in the prehospital setting.
Kosowsky
JM
University of Cincinnati, Cincinnati, OH.
Gasaway
MD
Stephanides
SL
Ottaway
M
Sayre
MR