Sahu Novneet, Matthews Patrick, Groner Kathryn, Papas Mia A, Megargel Ross
1Christiana Care Health System,Newark,DelawareUSA.
Prehosp Disaster Med. 2017 Dec;32(6):610-614. doi: 10.1017/S1049023X17006677. Epub 2017 Jul 3.
Introduction Continuous positive airway pressure (CPAP) improves outcomes in patients with respiratory distress. Additional benefits are seen with CPAP application in the prehospital setting. Theoretical safety concerns regarding Basic Life Support (BLS) providers using CPAP exist. In Delaware's (USA) two-tiered Emergency Medical Service (EMS) system, BLS often arrives before Advanced Life Support (ALS). Hypothesis This study fills a gap in literature by evaluating the safety of CPAP applied by BLS prior to ALS arrival.
This was a retrospective, observational study using Quality Assurance (QA) data collected from October 2009 through December 2012 throughout a state BLS CPAP pilot program; CPAP training was provided to BLS providers prior to participation. Collected data include pulse-oximetry (spO2), respiratory rate (RR), heart rate (HR), skin color, and Glasgow Coma Score (GCS) before and after CPAP application. Pre-CPAP and post-CPAP values were compared using McNemar's and t-tests. Advanced practitioners evaluated whether CPAP was correctly applied and monitored and whether the patient condition was "improved," "unchanged," or "worsened."
Seventy-four patients received CPAP by BLS; CPAP was correctly indicated and applied for all 74 patients. Respiratory status and CPAP were appropriately monitored and documented in the majority of cases (98.6%). A total of 89.2% of patients improved and 4.1% worsened; CPAP significantly reduced the proportion of patients with SpO224, and cyanosis (P<.01). The GCS improved from mean (standard deviation [SD]) 13.9 (SD=1.9) to 14.1 (SD=1.9) after CPAP (mean difference [MD]=0.17; 95% CI, -0.49 to 0.83; P=.59). The HR decreased from 115.7 (SD=53) to 105.1 (SD=37) after CPAP (MD=-10.9; 95% CI, -3.2 to -18.6; P<.01). The SpO2 increased from 80.8% (SD=11.4) to 96.9% (SD=4.2) after CPAP (MD=17.8; 95% CI, 14.2-21.5; P<.01).
The BLS providers were able to determine patients for whom CPAP was indicated, to apply it correctly, and to appropriately monitor the status of these patients. The majority of patients who received CPAP by BLS providers had improvement in their clinical status and vital signs. The findings suggest that CPAP can be safely used by BLS providers with appropriate training. Sahu N , Matthews P , Groner K , Papas MA , Megargel R . Observational study on safety of prehospital BLS CPAP in dyspnea. Prehosp Disaster Med. 2017;32(6):610-614.
引言 持续气道正压通气（CPAP）可改善呼吸窘迫患者的预后。在院前环境中应用CPAP还可带来额外益处。对于基础生命支持（BLS）人员使用CPAP存在理论上的安全担忧。在美国特拉华州的两级紧急医疗服务（EMS）系统中，BLS通常比高级生命支持（ALS）先到达。假设 本研究通过评估BLS在ALS到达之前应用CPAP的安全性，填补了文献中的空白。
这是一项回顾性观察研究，使用从2009年10月至2012年12月在全州BLS CPAP试点项目中收集的质量保证（QA）数据；在参与之前，为BLS人员提供了CPAP培训。收集的数据包括应用CPAP前后的脉搏血氧饱和度（SpO₂）、呼吸频率（RR）、心率（HR）、皮肤颜色和格拉斯哥昏迷评分（GCS）。使用McNemar检验和t检验比较CPAP应用前和应用后的数值。高级从业者评估CPAP是否正确应用和监测，以及患者状况是“改善”、“不变”还是“恶化”。
74例患者接受了BLS的CPAP治疗；所有74例患者CPAP指征明确且应用正确。大多数病例（98.6%）对呼吸状况和CPAP进行了适当监测并记录。共有89.2%的患者病情改善，4.1%的患者病情恶化；CPAP显著降低了SpO₂＜90%、呼吸频率＞24次/分以及发绀患者的比例（P＜0.01）。CPAP应用后，GCS从平均（标准差[SD]）13.9（SD = 1.9）提高到14.1（SD = 1.9）（平均差值[MD] = 0.17；95%置信区间，-0.49至0.83；P = 0.59）。CPAP应用后，HR从115.7（SD = 53）降至105.1（SD = 37）（MD = -10.9；95%置信区间，-3.2至-18.6；P＜0.01）。CPAP应用后，SpO₂从80.8%（SD = 11.4）升至96.9%（SD = 4.2）（MD = 17.8；95%置信区间，14.2 - 21.5；P＜0.01）。
BLS人员能够确定适合应用CPAP的患者，正确应用CPAP，并适当监测这些患者的状况。接受BLS人员CPAP治疗的大多数患者临床状况和生命体征得到改善。研究结果表明，经过适当培训的BLS人员可以安全地使用CPAP。萨胡N、马修斯P、格罗内尔K、帕帕斯MA、梅加格尔R。院前BLS CPAP治疗呼吸困难安全性的观察性研究。院前急救与灾难医学。2017；32（6）：610 - 614。
