Brief ReportNoninvasive ventilation use in French out-of-hospital settings: a preliminary national survey
Introduction
During the last 20 years, noninvasive ventilation (NIV) has proved to be beneficial in the treatment of acute respiratory failure (ARF) in critical care units, thus reducing endotracheal intubation and mortality rates, and its indications have been optimized [1], [2]. Concerning acute cardiogenic pulmonary edema (ACPE), the benefit of continuous positive airway pressure (CPAP) is equivalent to that of pressure support ventilation (PSV) [3]. In acute exacerbation of chronic obstructive pulmonary disease (COPD), PSV is recommended [4]. Noninvasive ventilation could also be used with the “do-not-intubate” patients.
The use of NIV by emergency physicians has also shown to be of interest in ACPE and in ARF secondary to COPD [5], [6]. Trained medical teams and appropriate equipment are required. Nevertheless, an increased risk of death was reported in the event of delayed intubation or noncompliance to validated indications, highlighting the potential iatrogenesis related to the use of the device without adequate expertise [7].
The few published studies concerning out-of-hospital care focus mainly on the feasibility, clinical benefits, and cost-benefit aspect of CPAP devices during ACPE [8], [9], [10]. Studies using PSV in the out-of-hospital environment are rare [11]. However, a benefit for patients having ARF secondary to COPD is expected. In this study, PSV failure rates were similar to those performed at in-hospital level [12]. Continuous positive airway pressure mode is considered as simple as PSV to use. Paramedics can be trained to use CPAP for patients in ACPE or with other severe respiratory failure [11].
In 2006, a French consensus meeting on NIV drew up some recommendations, according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) grid [13]. In the out-of-hospital setting, recommendations were to use CPAP mode to treat ACPE, with free-flow system devices. Pressure support ventilation use for the treatment of ARF in COPD is strictly limited to trained teams with adapted equipment (Table 1) [2]. Current practices in the use of NIV and compliance with the recommended guidelines have not been studied in France or in other countries. The objective of our study was to describe NIV practices (NIV mode: CPAP or PSV; indications) in French SMUR at a national level and their compliance with national consensus guidelines.
Section snippets
Methods
In France, out-of-hospital life-threatening cases are managed by a medical team (emergency physician with a nurse and a basic paramedic) from out-of-hospital mobile intensive care units (called SMUR), the latter being coordinated by an emergency medical call center (called SAMU) [14]. The SMUR are located in hospital, and each one has one or several medical teams.
In 2006, a standardized online questionnaire was sent to 218 SMUR centers that were registered in SAMU de France Database. The SMUR
Results
One hundred eighteen SMUR (54%) answered. One hundred seven (91%) of them were equipped with NIV devices. Ninety-six SMUR (81%) had access to a CPAP device, 69 (58%) to a PSV ventilator, with 58 (49%) having access to both of them. Among the 96 SMUR that reported having a device that could be used in CPAP mode, it was available in every vehicle for 69 (72%) of them. Among the 69 SMURs that reported having a ventilator that could be used in PSV mode, it was available in every vehicle for 37
Discussion
The prevalence of NIV use and compliance with national guidelines have not been previously well studied in the out-of-hospital setting [11]. Our study is the very first one that describes NIV use (indication, mode) in daily practice in the out-of-hospital setting. Our survey shows heterogeneous practice among different SMUR. Use of NIV and mode choice is variable according to pathologies and not always in accordance with recommendations [2]. In addition, for many SMUR, devices are not always
Acknowledgment
The authors thank Anna Ozguler, Thierry Lentz, and Maidei Gugu Kabayadondo for assistance with language editing and SAMU de France for making available its database.
Statement of interest: None declared.
References (15)
- et al.
The use of non-invasive ventilation in emergency department patients with acute cardiogenic pulmonary edema: a systematic review
Ann Emerg Med
(2006) - et al.
The use of noninvasive positive pressure ventilation in the emergency department: results of a randomized clinical trial
Chest
(1998) - et al.
An observational study of noninvasive positive pressure ventilation in out-of-hospital setting
Am J Emerg Med
(2008) - et al.
Correlation of arterial PCO2 and PETCO2 in prehospital controlled ventilation
Am J Emerg Med
(2005) International Consensus Conference in Intensive Care Medicine: non-invasive positive pressure ventilation in acute respiratory failure. Organised by the American Thoracic Society, the European Respiratory Society, the European Society of Intensive Care Medicine, and the Societe de Reanimation de Langue Francaise, and approved by the ATS Board of Directors
Intensive Care Med
(2001)- Robert R, Bengler C, Beuret P et al. Consensus conference on non-invasive positive-pressure ventilation in acute...
Noninvasive ventilation in acute cardiogenic pulmonary edema
Curr Opin Crit Care
(2008)
Cited by (4)
Noninvasive Ventilation in Critically Ill Patients
2015, Critical Care ClinicsCitation Excerpt :In Europe, NIV use ranges from 35% of ventilated patients in intensive care units (ICUs) to about (60%) in respiratory ICUs (RICUs) or emergency departments (EDs).16 In North America, where NIV is most often begun in the ED, data are similar to those from Europe.15,17,18 Nevertheless, several studies have found that the use of NIV varies widely between hospitals and countries.