Immediate non-invasive ventilatory (NIV) support in patients with severe respiratory failure on the emergency ward (ED)- Experience of a 6 months pilot

Project

Immediate non-invasive ventilatory (NIV) support in patients with severe respiratory failure on the emergency ward (ED)- Experience of a 6 months pilot

Completed · 2013 until 2015

Rüdiger Jochen, Kleger Gian-Reto, Diethelm Markus, Osterwalder Joseph, Brutsche Martin

Type

Fundamental Research

Range

Monocentric project at KSSG

Units

Pneumologie und Schlafmedizin, Intensivmedizin, Allgemeine Innere Medizin | Hausarztmedizin und Notfallmedizin, Notfallzentrum

Status

Completed

Start Date

2013

End Date

2015

Financing

Self Financed

Brief description/objective

Background
Patients with severe respiratory failure (SRF) are often in need for rapid ventilatory support. Availability of immediate NIV is often limited to the intensive care unit (ICU). We hypothesized that immediate initiation of NIV in the ED is feasible and may lead to benefit in these patients.

Methods and Setting
Multidisciplinary consensus (respiratory therapists (RTs), nurses and physicians of the ED, pneumology, general internal medicine, and ICU):

1) Patients admitted to the ED with SRF defined as either respiratory rate (RR)>25/min, SpO2<92% despite 6L/min supplemental oxygen and/or hypoventilation (paCO2>7.4kPa)
2) Initiation of NIV by RTs together with a pulmologist within 30 min after calling the RTs
3) NIV by RTs in the ED was limited to regular office hours (otherwise standard treatment)
4) The ED team remained responsible for patient placement and treatment.

Results
Within 6 months, 55 patients qualified for acute NIV within the hospital. 44 cases were assessed on the ED. 31 of them occurred during regular working hours (70%). 3 additional patients received NIV because the RT team was available for a different reason. 2 did not receive NIV (clinical improvement or abdominal distress).

Main reasons for SRF were COPD, cardiogenic pulmonary edema and pneumonia in 16, 6, 3, respectively. RR, acidosis and hypercarbia improved in all but 2 patient within 60 min of NIV (RR 30+/-8/min to 19+/-6/min, pH 7.32+/-0.11 to 7.39+/-0.07, and pCO2 8.13+/-2.21kPa to 6.32+/-2.26kPa). 13 patients were placed on ICU (41%), 4 had been intubated (13%). 5 of 13 patients with a no-resuscitation order died, an important indication for NIV in such cases was palliation of dyspnea.

Conclusion
Acute NIV on the ED is feasible and resulted in substantial clinical benefit, even in palliative settings. Two thirds of all cases could be treated by a team working regular office hours. Immediate NIV in SRF bridges optimal patient management between ED, ICU and medical ward.