UNIVERSITY

OF TASMANIA

Menzies
Research
Institute
Tasmania

CPAP in the treatment of acute

cardiogenic pulmonary oedema patients in
the pre-hospital setting
Michael A Austin
Senior Emergency
g
y Medicine Trainee,,
Royal College of Physician and Surgeons of Canada

ACEMNov.2012,Hobart,TAS

UNIVERSITY
OF TASMANIA

Menzies
Research
Institute
Tasmania

Arandomisedcontrolledtrialofcontinuouspositive
A d i d t ll dt i l f ti
iti
airwaypressure(CPAP)inthetreatmentofacute
cardiogenicpulmonaryoedema(ACPO)patientsinthe
prehospitalsetting
MichaelAAustin1,2,3,KEWills3,DKilpatrick4,MGibson5,EHWalters3,4
1.

DepartmentofEmergencyMedicine,UniversityofOttawa,Ontario,Canada

22.

OttawaHospitalResearchInstitute
Ottawa Ontario Canada
OttawaHospitalResearchInstitute,Ottawa,Ontario,Canada

3.

MenziesResearchInstituteTasmania,Australia

4.

SchoolofMedicine,UniversityofTasmania,Australia

5.

AmbulanceTasmania,Australia

Thankyou
ProfessorHaydnWalters
P f
H d W lt
DrKarenWills
ProfessorDavidKilpatrick
MichaelGibson
RoyalHobartHospitalEmergencyDepartment
ProfessorIanStiell&OttawaHospitalResearch
Institute(OHRI)

Sponsors Thankyou!
NHMRC Centre of Research Excellence
(CRE) for Chronic Respiratory Disease

Fisher and Paykal (suppliers of the

Whisperflow CPAP device)

Ambulance Tasmania (Training and IT

support)
Ambulance Tasmania

Disclosure
Disclosure
No conflicts of interests to disclose

Background
Congestiveheartfailure(CHF)iscommon
IIn2008,CHFoccurredin5.7millionAmericans,andin

8 CHF
di illi A
i
di
10millionEuropeans

Background
Substantialburden12%totalhealthcostswith70%
Substantialburden1
2%totalhealthcostswith70%
relatedtohospitalisation
Coursecharacterizedbyepisodesofacute
breathlessnessandhypoxia
Thediseaseisassociatedwithpoorprognosisand
reducedqualityoflife

Physiology

Increasedbackpressureofpulmonaryvenous
circulation precipitatesextravasationsoffluidinto
thelungs
FluidcausesintrapulmonaryshuntingandVQ
FluidcausesintrapulmonaryshuntingandV
Q
mismatch(redistributionofbloodflow)

Clinical
Presentation
ClinicalPresentation
Tachypnoea
Difficultybreathing
Hypoxaemia
anxiety
i t

Outof
Out
ofhospitalManagement
hospital Management

Standardprehospitalmanagementincludes:
Highflowoxygen
Nitroglycerin
gy
severecasesassistedventilation
(Frusemide Morphine)
(Frusemide,Morphine)

TheprehospitaluseofCPAPventilationisa
relativelynewmanagementforacutecardiogenic
pulmonaryoedema(ACPO),littleevidence
l
d
(ACPO) li l id

CochraneReview2008
21St di 1071 ti t
21Studies,1071patients
NPPVsignificantlyreduced
hospitalmortality(RR0.6,95%CI0.45to0.84)
endotrachealintubation(RR0.53,95%CI0.34to0.83)
(
53, 95
34
3)
withnumbersneededtotreatof13and8,respectively

AnnalsofEmergencyMedicine2008
71patients(20022006)
IIntubation17/34(50%)usualcareversus7/35(20%)
t b ti / ( %)
l

/ ( %)
CPAPgroup
Mortality12/34(35%)usualcareversus5/35(14%)CPAP
li
/ ( )
l
/ ( )

Objectives
j
Goal:Todeterminewhetherpatientsinsevere
respiratorydistressfromACPOtreatedwithCPAPin
p
y
theprehospitalsettinghavealowermortalitythan
thosetreatedwithusualcare.
ACPOpatient

ContinuousPositive
AirwayPressure
y

InspiredPositive
PressureVentilation

(CPAP)

(IPPV)

Methods
Randomised,controlled,parallelgrouptrial
Randomisednumbergenerator(excel)
opaqueenvelope

Methods
InclusionCriteria:
Patients>18yrsofage,severerespiratorydistress,
hypoxia,impedingrespiratoryfailure
PresumedfromhistoryandexamtobeAcute
CardiogenicPulmonaryoedema(ACPO)
g
y
(
)
ExclusionCriteria:
Primarypresentationforanotherconditione.g.
AECOPDorAsthma

Hobart,Tasmania(June2009
Hobart,Tasmania(June2009
July2010)
,
(
y
)
Population300,000(UrbanandRuraldistribution)
ParamedicsandIntensiveCareParamedicsalltrained
inIPPVandCPAP

Outcomes
PrimaryOutcome:
Pi
O t
Inhospitalmortalityfromcardiovascularcause
SecondaryOutcomes:
Lengthofhospitalstay
Bloodgasresults
g
Requirementforintubation
Vitalsigns(BP,HR,Respiratoryrate,
g ( , ,
p
y
,
oxygensaturation,GCS)

Randomisation
Randomisation
Intervention
activearm
receivedCPAPdeliveredbyWhisperflow

Whisperflow
14 16L/minOxygen
1416L/minOxygen
Flow120L/min
Oxygendelivered2833%
PEEP 10cmofH20
WHY?
1 Controlledoxygendelivery
1.
Controlledo gendeli er
2. Consumptionofoxygen

Randomisation
Randomisation
Intervention
controlarm
receivedinspiredpositivepressureventilation
(b
(bagging),administeredbybagvalvemaskwith
i ) d i i
db b
l
k ih
oxygenattachedatrateof815l/min

AmbulanceTasmaniaGuidelines

basicsupport(Oxygen)
nitroglycerinesublingual
incrementaldosesstartingat400mcgto1600mcg
Q5min(BP>100mmHg)

AmbulanceTasmaniaGuidelines
SupportiveIPPVforsevererespiratorydistress
pp
p
y
Frusemide40mgIV(severerespiratorydistress)
Morphine1 2mgIV(treatanxiety)
Endotrachealintubationwasperformedifpatients
conditionworsenedandpatientsbecameunresponsive
p
p

ACPOCases
N=377

Control
(Usualcare)
n=26

randomised
N=50

327excludednot
ventilated

Active
(CPAP)
n=24
4

analysis
Analyzed
A
l d
n=26

Analyzed
A
l d
n=24

outcomes
Allcausemortality9

Allcausemortality

Cardiovascularcausemortality9

Cardiovascularcausemortality1

PreTreatmentBaselineCharacteristics
Pre
Bagging
gg g
N=26

CPAP
N=24

Mean(SD)

Mean(SD)

Male%

61%

29%

Age (years)
Age

78.3 (11.8)
78.3

81.5 (11.9)
81.5

PreHospitalTreatmentTime
(Minutes)

35.3(19.9)

42.3(21.5)

InitialOxygenSaturation(%)

75.5 (21.7)

77.1(14.2)

Initial Respiratory Rate

31.1 (11.6)

34.2 (10.8)

InitialSystolicBP(mmHg)

160.2(61.7)

168.8(24.6)

InitialGCS

13.7(3.2)

14.1 (2.2)

(breaths/min)

PostTreatmentBaselineCharacteristics
Post
Bagging
N=26

CPAP
N=24

Mean(SD)

Mean(SD)

Oxygen Saturation (%)

OxygenSaturation

95 1 (4.8)
95.1
(4 8)

87 5 (7.1)
87.5
(7 1)

RespiratoryRate(breaths/Min)

27.5(9.0)

32.3(9.7)

SystolicBloodpressure(mmHg) 143.3(32.0)

136.4(22.9)

GCS

14.1(1.1)

13.6(3.1)

Results
Bagging
n=26

Results
Mortality

CPAP
n=24

P value
Pvalue

Allcause
ll

9(35%)
( )

3(14%)
( )

0.09

Cardiovascular
C
Cause

9(35%)

1(4%)

0.04

Hospitalstay

5.4(5.2)

3.1(2.3)

y ((SD))
Days

0.05

Mortality(Cardiovascularcause)
y(
)
35.0%
8
D
Deaths

NNH=6
p=0.04

10.0
00
4

9.0
4.0%

10
1.0
All Patients
(N=50)

CPAP
(N=24)

Bagging
(N=26)

Timetodeathinhours
<24 h
hours

< 72 hours

2.0

10
1.0
70
7.0

< 48 hours

Results
Bagging
n=26

Results
Mortality

CPAP
n=24

P value
Pvalue

Allcause
ll

9(35%)
( )

3(14%)
( )

0.09

Cardiovascular
C
Cause

9(35%)

1(4%)

0.04

Hospitalstay

5.4(5.2)

3.1(2.3)

y ((SD))
Days

0.05

BloodGasresultstaken
within30minofarrival

Results

Bagging
n=21

BG(<30mins)

pHmmHg(SD)

7.22(0.12)

7.32(0.08)

0.002

pCO2mmHg(SD)

56.2(14.5)

46.2(12.1)

0.02

BicarbmmHg(SD)

22.0(4.2)

23.0(3.4)

0.41

pO2mmHg(SD)

CPAP
n=23

Pvalue

n=14

n=9

107 2(92.6)
107.2
(92 6)

95 7(48.6)
95.7
(48 6)

0 73
0.73

Limitations
Limitations
smallsamplesize
Novalidatedseverityofrespiratorydistressscore
wasusedtodetermineeligibility(maylimited
comparability with other studies)
comparabilitywithotherstudies)
Lowrateofarterialbloodgassampling
24/50(48%)
Couldnotdeterminetheeffectofinhospital
managementonoutcome(standardisBiPAP)

Discussion
ThispilotRCTfoundthatCPAPforACPOreducedthe
riskofdeathby88%
i k f d th b 88% (RR 00.12
12 95% CI (0
(0.02,
02 0
0.88)
88) p=0.04)
0 04)
withNNHof6

ThisisconsistentwiththeCochranereviewresultsand
trendsfromThompsonetal.
Therewasareductioninlengthofhospitalstay
Patientswerelessacidoticandhypercarbicwhen
Patients
were less acidotic and hypercarbic when
treatedwithCPAP

Discussion Hyperoxia
Discussion
Discussion

Oxygen Saturation (%)

Bagging
N 26
N=26
Mean (SD)

CPAP
N 24
N=24
Mean (SD)

95.1 (4.8)

87.5 (7.1)

Discussion
Discussion hyperoxia
Discussion
hyperoxaemiacancausecoronaryartery
vasoconstrictionandreducedcoronaryartery
bloodflow
Troponinrise25%inpatientwithCOPD
opo
se 5% pat e t t CO ((Becker1996)
ec e 996)
Increasedinfarctsizeandtrendtowardmortality
in ACS (Rawlings1967)
inACS
(Rawlings 1967)

Discussion
Discussion hyperoxia
Discussion
causespartialcollapseofsomelungunits,a
conditionknownasabsorptionatelectasis
worseningventilationperfusionmismatch
worsening
ventilation perfusion mismatch
worseninghypercarbiaandacidosis

Conclusions
Conclusions
Thispilottrialwasconsistentwiththecurrent
literatureonCPAPinthetreatmentofACPO
Reductioninriskofmortality
Reductioninlengthofhospitalstayand
Reduction
in length of hospital stay and
respiratoryacidosis
ThereforesupportingtheuseofCPAPforpatients
Therefore
supporting the use of CPAP for patients
withsevererespiratorydistresssecondaryto
ACPO

Conclusions
Conclusions
Resultsfromthisstudyalsosupportthecaution
intheuseofhyperoxiaforthispatient
population

NextStep..
Publishtheseresults
AlargeRCTisneededtovalidateCPAPs
g
effectivenessinthemanagementofACPOin
theprehospitalsetting