University of California, San Francisco, Department of Emergency Medicine, San Francisco, California.
University of Arizona, Department of Emergency Medicine, Tucson, Arizona.
West J Emerg Med. 2020 Jun 25;21(4):849-857. doi: 10.5811/westjem.2020.2.43896.
We developed evidence-based recommendations for prehospital evaluation and treatment of adult patients with respiratory distress. These recommendations are compared with current protocols used by the 33 local emergency medical services agencies (LEMSA) in California.
We performed a review of the evidence in the prehospital treatment of adult patients with respiratory distress. The quality of evidence was rated and used to form guidelines. We then compared the respiratory distress protocols of each of the 33 LEMSAs for consistency with these recommendations.
PICO (population/problem, intervention, control group, outcome) questions investigated were treatment with oxygen, albuterol, ipratropium, steroids, nitroglycerin, furosemide, and non-invasive ventilation. Literature review revealed that oxygen titration to no more than 94-96% for most acutely ill medical patients and to 88-92% in patients with acute chronic obstructive pulmonary disease (COPD) exacerbation is associated with decreased mortality. In patients with bronchospastic disease, the data shows improved symptoms and peak flow rates after the administration of albuterol. There is limited data regarding prehospital use of ipratropium, and the benefit is less clear. The literature supports the use of systemic steroids in those with asthma and COPD to improve symptoms and decrease hospital admissions. There is weak evidence to support the use of nitrates in critically ill, hypertensive patients with acute pulmonary edema (APE) and moderate evidence that furosemide may be harmful if administered prehospital to patients with suspected APE. Non-invasive positive pressure ventilation (NIPPV) is shown in the literature to be safe and effective in the treatment of respiratory distress due to acute pulmonary edema, bronchospasm, and other conditions. It decreases both mortality and the need for intubation. Albuterol, nitroglycerin, and NIPPV were found in the protocols of every LEMSA. Ipratropium, furosemide, and oxygen titration were found in a proportion of the protocols, and steroids were not prescribed in any LEMSA protocol.
Prehospital treatment of adult patients with respiratory distress varies widely across California. We present evidence-based recommendations for the prehospital treatment of undifferentiated adult patients with respiratory distress that will assist with standardizing management and may be useful for EMS medical directors when creating and revising protocols.
我们制定了针对成人呼吸窘迫患者的院前评估和治疗的循证推荐。这些推荐与加利福尼亚州 33 个当地紧急医疗服务机构（LEMSA）目前使用的协议进行了比较。
我们对成人呼吸窘迫患者院前治疗的证据进行了回顾。对证据质量进行了评级，并用于制定指南。然后，我们比较了这 33 个 LEMSA 的呼吸窘迫协议与这些推荐的一致性。
采用 PICO（人群/问题、干预、对照组、结局）问题调查，包括氧疗、沙丁胺醇、异丙托溴铵、皮质类固醇、硝酸甘油、呋塞米和无创通气的治疗。文献综述显示，对于大多数急性重病患者，将氧浓度滴定至不超过 94-96%，对于急性慢性阻塞性肺疾病（COPD）加重的患者则滴定至 88-92%，与死亡率降低相关。在支气管痉挛性疾病患者中，数据显示沙丁胺醇给药后症状和峰值流量改善。院前使用异丙托溴铵的相关数据有限，且获益并不明确。文献支持在哮喘和 COPD 患者中使用全身皮质类固醇来改善症状并减少住院。有微弱的证据支持在急性肺水肿（APE）合并高血压危象的重症患者中使用硝酸盐，而中度证据表明怀疑患有 APE 的患者院前使用呋塞米可能有害。文献表明，无创正压通气（NIPPV）在治疗急性肺水肿、支气管痉挛和其他疾病引起的呼吸窘迫是安全有效的。它降低了死亡率和插管需求。在每个 LEMSA 的协议中都发现了沙丁胺醇、硝酸甘油和 NIPPV。在一部分协议中发现了异丙托溴铵、呋塞米和氧浓度滴定，而在任何 LEMSA 协议中都没有开皮质类固醇。
加利福尼亚州各地对成人呼吸窘迫患者的院前治疗差异很大。我们提出了针对成人呼吸窘迫未分化患者的院前治疗的循证推荐，这将有助于标准化管理，并可能对 EMS 医疗主任制定和修订协议时有所帮助。
