Læknablaðið : fylgirit - 15.06.2002, Blaðsíða 14

ABSTRACTS / ICELAND 2002: EMERGENCY MEDICINE BETWEEN CONTINENTS
therapy) in patients with ARF, with particular reference to blood
gas effects, intubation rate and mortality. Design: retrospective
study.
Methods: between August 2001 and January 2002,53 patients (pts)
received NIV for an episode of ARF. NIV was given by face mask
with a ventilatory assist device (Pulmonetics - LTV 1000).
Results: 39 pts received NIV for acute hypoxemic respiratory
failure (27 acute cardiogenic pulmonary edema (ACPE) - mean
age 76.4±6.6; 12 ALI/ARDS - mean age 74.18±9.51) and 14 pts
received NIV for acute exacerbation of COPD (mean age 76±3).
Failure was defined as the need for invasive ventilation. NIV was
successful in 47 pts (88%); all pts who underwent NIV survived,
while 4 (66%) of the pts who needed invasive ventilation died. NIV
was successful in all pts with ACPE, in all but one of pts with acute
exacerbalion COPD and in 7/12 (58%) pts with ALI/ARDS.
Complications were rare: only 1 pt developed skin necrosis.
• ACPE: after the first hour of NIV treatment significant changes
in clinical-physiological parameters were found (improvement
in Pa02/Fi02, pH, respiratory rate, heart rate, PaC02, systolic
blood pressure, Sp02; p < 0.01 in all samples). Five pts with
NSTEMI were treated successfully with NIV; 4 of these showed
ECG or cardiac markers alteration before starting NIV, only one
developed ECG alterations a few hours after NIV treatment. All
5 pts had a story of CAD or CHF.
• COPD: in acute exacerbation of COPD a significant improve-
ment of pH, respiratory rate, PaC02 and Sp02 was observed
after 1 hour of trealment (pH 7.23 to 7.30; PaC02 81 to 69; RR:
35 to 28; Sp02: 85 to 92; p < 0.05 in all samples). Only 1 pt
required invasive ventilation.
• ALI/ARDS: of 12 pts with ALI/ARDS, 7 successfully under-
went NIV trial; in this group a significant improvement of
Pa02/Fi02, RR and Sp02 (Pa02/Fi02:68 to 128; RR: 36 to 26;
Sp02:75 to 94- p<0.05 for all samples) was observed after 1 hour
of treatment, while no changes were found in the failure group.
Of the 5 pts who required invasive ventilation, 3 died.
Condusion: NIV, delivered by face mask, can result in early
improvement of physiological parameters in pts with acute exacer-
bation of COPD and in pts with ACPE. A trial with NIV may be
tried in pts with ALI/ARDS, but if no improvement is seen in the
first hours endotracheal intubation should be carried out as soon as
possible.
015- Airway/Respiratory Emergencies
Non invasive mechanical ventilation (NIV) vs. continuous
positive airway pressure (CPAP) in acute cardiogenic pulmonary
edema (ACPE)
Ferrari G, De Salvia A, Aprá F, Petrino R, Olliveri F
St. Giovanni Bosco Hospital -Turin. Italy
Background: Cardiogenic pulmonary edema is a frequent cause of
respiratory failure. CPAP has been shown to be effective in patients
(pts) with ACPE who remain hypoxic despite standard medical
therapy, while NIV is generally reserved for pts who fail a CPAP
trial.
Objective: To assess ACPE patients' response to NIV or CPAP
treatment.
Methods: A retrospective study was undertaken of 52 pts with
clinical-radiological diagnosis of ACPE. In addition to standard
medical therapy (oxygen, nitrates, diuretics and morphine), pts
were treated with NIV or CPAP at the discretion of the physician in
the Emergency Department. 27 pts received NIV and 25 CPAP
through a face mask with a ventilatory assist device (Pulmonetics -
LTV 1000). Fi02 was started at 1 and then decreased to keep
saturation > 92%; PSV was started with 10 cmH20 and increased
to obtain an expiratory tidal volume > 7 ml/kg and to decrease the
respiratory rate (RR); CPAP/PEEP was started at 5 cmH^O and
incremented to reach pulse oximetry saturation > 92%. Failure was
defined as the need for invasive ventilation.
Results: initial mean values on Fi02 lwith: NIV: Pa02/Fi02 120,
respiratory rate (RR) 32, pH 7.23, PaC02 64 - CPAP: Pa02/Fi02
109, RR 32, pH 7.19, PaC02 62. After 60 minutes of NIV/CPAP
improvement was statistically significant in both groups: NIV:
Pa02/Fi02 189. RR 25, pH 7.31, PaC02 55 - CPAP: Pa02/Fi02
168. RR 26, pH 7.29, PaC02 51; p <0.05 in all groups. All pts that
underwent NIV survived and no one required invasive ventilation,
while, in the CPAPgroup,2 pts (8%) died and 3 pts (12%) required
invasive ventilation for no improvement after CPAP trial. Duration
of ventilation and length of stay were similar in both groups (p=ns).
Percentage of myocardial ischemia (NSTEMI) were similar: 5/27
pts (18%) with NSTEMI were successfully treated with NIV, 4 of
these showed increased cardiac markers or ECG alterations before
NIV trealment. 6/25 pts (24%) with NSTEMI were successfully
treated with CPAP, 4 showed ECG or enzymatic alterations on
admission.
Condusion: both CPAP and NIV can result in early physiological
improvement and are effective treatments in pts with ACPE; NIV
especially can reduce the need for endotracheal intubation and
invasive ventilation. The proportion of myocardial ischemia was
similar in the two groups; we found no association between NIV
and myocardial infarction.
0 16- Airway/Respiratory Emergencies
Success rate of airway management by residents in a
prehospital emergency setting: a retrospective study
Albrecht E, Yersin B, Hugli O, Spahn DR, Fishman D
Emergency Department and Anesthesiology Department, University Hospital
(CHUV), Lausanne, Switzerland
Objectíve: The objectives of this retrospective study were to assess
i) the success rate of prehospital patient airway management by
residents according to a standardized protocol and ii) the success of
oral endotracheal intubation (ETI) in a level I trauma center.
Methods: Our level 1 emergency and trauma center has performed
13,537 prehospital medical interventions in the last 5 years (1996-
2001). The minimal required training for residents rotating in the
prehospital emergency team was either 1 year in a university
anesthesiology department or an internal medicine resident having
performed 20 ETI under supervision in the operating room.
Defined indications for oral endotracheal intubation are: (1)
head trauma with GCS < 8 (2) severe facial trauma (3) multiply
injured patient with shock (SBP < 90 mmHg) (4) burn patient with
inhalation syndrome (5) respiratory failure (RR > 35/min and
saturation < 90 % (6) cardiac arrest.
I) Among 13,537 medical records. 1,252 patients met the criteria
14 Læknablaðið/Fylgirit 45 2002/88