1. Prehospital CPAP Reduces Need For Intubation In Respiratory Emergencies Mark Marchetta, RN, BS, NREMT-P Mark Resanovich, EMT-P Aultman Health Foundation Canton, Ohio

2. Objective Determine if CPAP decreased intubation rates for:Determine if CPAP decreased intubation rates for: CHFCHF AsthmaAsthma COPDCOPD PneumoniaPneumonia Pulmonary EdemaPulmonary Edema

3. Hypothesis There is a significant decrease in intubation rates of patients who receive CPAP versus conventional oxygen therapyThere is a significant decrease in intubation rates of patients who receive CPAP versus conventional oxygen therapy

4. Methods Expedited IRB ApprovalExpedited IRB Approval Data collectionData collection May 9, 2005 to May 9, 2006May 9, 2005 to May 9, 2006

5. Methods - Inclusion Criteria Awake and able to follow commandsAwake and able to follow commands Over 17 years oldOver 17 years old Maintain and protect own airwayMaintain and protect own airway Two of the followingTwo of the following Resp rate greater than 24Resp rate greater than 24 Pulse Ox less than 94% at any timePulse Ox less than 94% at any time Use of accessory musclesUse of accessory muscles

6. Methods Study Group (CPAP)Study Group (CPAP) Formed by patients transported by 22 paramedic ambulances equipped with CPAPFormed by patients transported by 22 paramedic ambulances equipped with CPAP Control Group (Conventional O2 Therapy)Control Group (Conventional O2 Therapy) Formed by patients transported by 31 paramedic ambulances not equipped with CPAPFormed by patients transported by 31 paramedic ambulances not equipped with CPAP

7. Methods All PatientsAll Patients Intubation rates up to 12 hours post hospitalization were recordedIntubation rates up to 12 hours post hospitalization were recorded The time began when the patient arrived at the emergency departmentThe time began when the patient arrived at the emergency department

8. CHF – Largest Study Group (133) 51 patients in CPAP Group 1 Intubation 82 patients in Control Group 22 Intubations 25% Reduction

9. COPD – 2nd Largest Group (98) 55 patients in CPAP Group 3 Intubations 43 patients in Control Group 15 Intubations 30% Reduction

10. Asthma – 3rd Largest Group (26) 19 patients in CPAP Group 3 Intubations 7 patients in Control Group 2 Intubations 12% Reduction

11. Pul Edema – 4th Largest Group (22) 15 patients in CPAP Group 4 Intubations 7 patients in Control Group 6 Intubations 60% Reduction

12. Other – 5th Largest Group (19) Had Dx – Hypoxemia, Resp Acidosis, or Resp Failure, 5 patients in CPAP Group 2 Intubations 14 patients in Control Group 9 Intubations 24% Reduction

13. Pneumonia – (11) 3 patients in CPAP Group 0 Intubated 8 patients in Control Group 2 Intubated 25% Reduction

14. Diagnosi s CPAP Group (n=148)Control Group (n=161) Intubated Not Intubated IntubatedNot Intubated n=% % % % Total138.813591.25634.810565.2 Other 2395 Pulm Edema 41161 Pneumonia 0326 COPD 3521528 Asthma 31625 CHF 1502260

15. Results Intubation reduction = 26% with 95% CI (16.7, 35.3)Intubation reduction = 26% with 95% CI (16.7, 35.3) Chi-square = 31.968; p<0.001Chi-square = 31.968; p<0.001 Patients who did not receive CPAP were six times more likely to be intubated (ODDS Ratio=6.061)Patients who did not receive CPAP were six times more likely to be intubated (ODDS Ratio=6.061)

16. Conclusion As a group, patients who received prehospital CPAP had a significantly lower incidence of intubation when compared to the group of patients who received conventional oxygen therapy.As a group, patients who received prehospital CPAP had a significantly lower incidence of intubation when compared to the group of patients who received conventional oxygen therapy.

17. Excluded 70 Patient received CPAP and Excluded70 Patient received CPAP and Excluded 52 with DNR or made DNR with in 12 hours of hospitalization52 with DNR or made DNR with in 12 hours of hospitalization 15 with decreased LOC / unable to follow commands15 with decreased LOC / unable to follow commands 3 under age 173 under age 17

18. Strength – Largest Study SourceLocationSample Size Marchetta, et al 200753 ambulances – 1 ED in USA 309 Nava, et al 20035 ED’s in Italy130 Several studies with less than 40 patients

19. Strength - No Complications Strength - No Complications CPAP was not discontinued due to any complicationsCPAP was not discontinued due to any complications PneumothoraxPneumothorax Vomiting / AspirationVomiting / Aspiration HypotensionHypotension

20. Strength - Length of Stay CPAP group 355 days less LOSCPAP group 355 days less LOS $8000 per day ICU+Intubation$8000 per day ICU+Intubation $56,000 increased cost for VAP$56,000 increased cost for VAP CPAP + IntubationCPAP + Intubation 5.4 days less LOS5.4 days less LOS ICU Admission reduced 62%ICU Admission reduced 62%

21. Recognition PublishedPublished PresentedPresented Best ResearchBest Research National / InternationalNational / International

22. EMT-Basic Skill With the exception of IV and ECG, CPAP group did not receive ALS careWith the exception of IV and ECG, CPAP group did not receive ALS care Occasional proventilOccasional proventil Rare Lasix administrationRare Lasix administration No MorphineNo Morphine

23. EMT-B Skill in Other States Minnesota and WisconsinMinnesota and Wisconsin Over 600 EMT-B applications without complicationsOver 600 EMT-B applications without complications OklahomaOklahoma New MexicoNew Mexico FloridaFlorida Even FD Engines carry itEven FD Engines carry it