1. The challenges of pre-hospital emergency treatment of Chronic Obstructive Pulmonary Disease.
David Fitzpatrick1, Dr Donogh Maguire2, Dr Edward Duncan3
Clinical Research Paramedic, Scottish Ambulance Service/NMAHP RU
Consultant in Emergency Medicine, Monklands District General Hospital
Senior Research Fellow, Nursing Midwifery and Allied Health Professions Research Unit

2. Background
Scottish Ambulance Service responded to 27,093 patients with Chronic Obstructive Pulmonary Disease over past 12 months. (Equating to 6% of all calls; n=600,000)
Anecdotal evidence from Dr Donogh Maguire (Consultant in Emergency Medicine) suggested pre-hospital treatment of patients with Acute Exacerbation of COPD may be suboptimal.
Pre-hospital clinical guidelines recommend during an acute exacerbation of COPD oxygen saturations should be kept between 88-92% (JRCALC, 2009).
Despite these many patients with COPD treated with oxygen therapy in the pre-hospital environment have oxygen saturations recorded above 92%. (SAS Audit Data 2011/12)
Current evidence suggests hyperoxygenation in the pre-hospital environment can adversely effect patient outcome.

3. Literature
Hale et al suggest pre-hospital hyperoxygenation may be due to a lack of appropriate oxygen delivery equipment, for example:
Venturi entrainment devices
Nasal cannulae
Oxygen saturation probes
Durrington et al demonstrated that the provision of venturi masks could reduce the number of COPD patients receiving high flow oxygen therapy.
Scottish Ambulance Service carry Venturi entrainment devices and oxygen saturation probes. Nasal cannulae are being introduced.

4. Literature cont.
‘Mistrust’ of hypoxic drive theory?
New writes “excessive pre-hospital oxygen prescription stems in part from a poor understanding of the consequences and presentation of hypercapnia”

5. Literature cont. Recognition of COPD
Some studies have demonstrated confusion around the most appropriate management strategy for patients with COPD.
Prehospital:
Hale et al: ambulance clinicians identified only 58% of cases correctly.
Denniston et al: ambulance clinicians identified only 32% of COPD patients correctly.
Within hospital:
Joosten et al: demonstrated that 80% of patients received oxygen therapy in excess of 2 litres/min after admission to the Emergency Department

6. Literature cont. Oxygen alert cards?
Two previous studies have demonstrated only moderate success with alert cards in reducing pre-hospital hyperoxygentation:
Gooptu et al: 62% of patients (n= 33) were managed by ambulance clinicians according to the guidance provided on the card.
Wolstenholme et al: only 26% of patients (n=5) presented their card to the Health Care Professional during treatment.

7. Multimodal communication - A solution?
British Thoracic Society (2008). Emergency Oxygen Use in Adult Patients
An emergency card to be kept with mask and adaptor or in lifeline pod at premises.
A laminated emergency card suitable for a purse or wallet.
A lifeline pod kept in fridge with a label to be placed on front door of premises.
NHS 24 and General Practitioner informed (essential information stored).
Electronic ‘tagging’ of patients address with ‘Oxygen Alert’ by the Emergency Medical Dispatch Centre.
Personal communication Jacqueline Davidson (Respiratory Nurse Specialist, August 2010)

8. Presented COPD paper in June 2011 to SAS Medical Directorate
Presented COPD paper in June 2011 to SAS Medical Directorate. Fully supportive of system. Emergency Medical Despatch Centres (EMDC) electronically ‘tag’ at risk individuals. (only occurring in West of Scotland EMDC at present) But……..there is a lack of evidence supporting the multimodal system.

9. What next?
On-going collaboration between Scottish Ambulance Service and Nursing, Midwifery and Allied Health Professions Research Unit.
Possible future studies for discussion:
a cross-sectional study (n=27,000 calls) of oxygen therapy in known COPD cases in pre-hospital emergency care using data linkage between SAS dataset and CHI mortality data for Scotland.
a large scale trial to measure effectiveness of multimodal system in reducing hyper-oxygenation and mortality rates.