Cliff Reid has already mentioned this paper, but I’m just getting to it so here’s my thoughts.
This is an RCT of clinically diagnosed APO (pulmonary oedema) in the field by “mobile ICUs” of France. They have the highest ranked health care system in the world BTW. Their pre-hospital system is physician staffed and so that makes it markedly different from a lot of other places.
Randomised to either valve CPAP (not ventilator CPAP) at 10cm H20 vs O2. Everyone got a moderate dose of frusejuice (1mg/kg) and some nitrates. I confess I don’t know if 2mg/hr of Isosorbide Dinitrate is high or low, we use GTN…
Their outcome was unfortunately a mixture of (still important) physiologic parameters and not something like mortality.
n=124
They found no real difference.
This doesn’t mean it’s not a good idea, it’s always going to be difficult to prove real benefit with these numbers and these outcomes. Especially when it’s in a system contextually different from ours.
Frontin, Philippe, Vincent Bounes, Charles Henri Houzé-Cerfon, Sandrine Charpentier, Vanessa Houzé-Cerfon, and Jean Louis Ducassé. “Continuous positive airway pressure for cardiogenic pulmonary edema: a randomized study..” The American Journal of Emergency Medicine 29, no. 7 (September 2011): 775–781. PMID 20825901
And still, the CPAP for pulmonary oedema is doctor-dependant, but we tend to use it a lot more than we did before ! (I’m a nurse working in Paris’ pre-hospital ICU’s)
great to hear from someone in the system! thanks for the comment
do most of the interventions (eg setting up CPAP) occur during transit or would you spend time on scene trying to stabilise them first?
You’re welcome.
We treat most of the patients on scene before transportation (except rare cases), while the medical regulations finds us a place to go. This is what’s really different between french prehospital system, and the anglo-saxon one. You “scoop and run”, we “wait and see”, because we have a doc, a nurse and the ambulance driver (and sometimes an intern or student) so we can have a field diagnostic and begin treatment. For the APO we usually put the CPAP in the same time as the IV, with isosorbide dinitrate and furosemide to see if the patient respons to it. If he doesn’t, we ask for a bed in resuscitation unit (in here, “Réanimation”) because he’ll probably end up intubated, and if it seems to work fine, we ask for an ICU or even the ED.