[LS17] NPPV: pre-hospital and early use in acute pulmonary edema in Europe
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同時通訳付き】
In the past decade, the use of noninvasive positive pressure ventilation (NPPV) as an alternative to intubation and conventional ventilation has become a standard of care in emergency rooms and intensive care units. NPPV helps reduce the need for endotracheal intubations, decreases complication rates, and improves patient outcomes. Our group showed that benefits of NPPV is even striking in acute pulmonary edema (APE) patients when administered in the pre-hospital setting.
In APE, congestion affects lung function and increases intrapulmonary shunting, resulting in hypoxemia. A decrease in SpO2 may be detected even in mild forms of AHF. FiO2 should be increased up to 100% if necessary, according to SpO2, unless contra-indicated. Hyperoxia, however, should be avoided. NPPV reduces respiratory distress and may decrease the intubation and mortality rates, although data regarding mortality are less conclusive. NPPV should be started as soon as possible in patients with APE showing respiratory distress. Continuous positive airway pressure (CPAP) is a feasible technique in the prehospital setting because it is simpler than pressure-support positive end-expiratory pressure (PS-PEEP) and requires minimal training or equipment. NPPV is even started at home, during the first contact with either paramedics or physicians. On hospital arrival, patients who still show signs of respiratory distress should continue with NPPV, in case of acidosis and hypercapnia, particularly in those with previous history of COPD or signs of fatigue.
Thus, European experts recommended the followings (Mebazaa A et Eur Heart Journal 2015):
- Oxygenation should be monitored with pulse-oximetry (SpO2)
- Acid–base balance, complementing SpO2 monitoring, should be obtained on admission, especially in patients with APE or previous history of chronic obstructive pulmonary disease, using venous blood or especially in patients with cardiogenic shock through the arterial line
- Oxygen therapy should be considered in patients with APE having SpO2 <90%
- NPPV is indicated in patients with respiratory distress and should be started as soon as possible. Non-invasive ventilation decreases respiratory distress and also reduces the rate of mechanical endotracheal intubation.
In APE, congestion affects lung function and increases intrapulmonary shunting, resulting in hypoxemia. A decrease in SpO2 may be detected even in mild forms of AHF. FiO2 should be increased up to 100% if necessary, according to SpO2, unless contra-indicated. Hyperoxia, however, should be avoided. NPPV reduces respiratory distress and may decrease the intubation and mortality rates, although data regarding mortality are less conclusive. NPPV should be started as soon as possible in patients with APE showing respiratory distress. Continuous positive airway pressure (CPAP) is a feasible technique in the prehospital setting because it is simpler than pressure-support positive end-expiratory pressure (PS-PEEP) and requires minimal training or equipment. NPPV is even started at home, during the first contact with either paramedics or physicians. On hospital arrival, patients who still show signs of respiratory distress should continue with NPPV, in case of acidosis and hypercapnia, particularly in those with previous history of COPD or signs of fatigue.
Thus, European experts recommended the followings (Mebazaa A et Eur Heart Journal 2015):
- Oxygenation should be monitored with pulse-oximetry (SpO2)
- Acid–base balance, complementing SpO2 monitoring, should be obtained on admission, especially in patients with APE or previous history of chronic obstructive pulmonary disease, using venous blood or especially in patients with cardiogenic shock through the arterial line
- Oxygen therapy should be considered in patients with APE having SpO2 <90%
- NPPV is indicated in patients with respiratory distress and should be started as soon as possible. Non-invasive ventilation decreases respiratory distress and also reduces the rate of mechanical endotracheal intubation.