Prehospital CPAP: should we pause to catch our breath?

Continuous positive airway pressure (CPAP) improves outcome in acute cardiogenic pulmonary oedema (ACPO) and is increasingly available in emergency departments. In theory, reducing delay to starting CPAP could benefit patients by helping to re-establish haemodynamic stability, but it is not known whether equipping ambulances and training staff in this technique is safe and both clinically and cost effective. Plaisance and colleagues from Paris conducted a randomised trial of 124 patients in the two-tier emergency medical system involving fire rescue personnel and anaesthetists or emergency physicians, together with an anaesthetic nurse, driver and medical student. Patients with ACPO who remained hypoxic despite high-flow oxygen were randomised to early or late CPAP, with the early group receiving “standard” medical treatment (intravenous diuretic, nitrate and nicardipine) before CPAP was applied. Inotropic support was added at the discretion of the attending doctor. While the authors conclude that prehospital CPAP provided within 15 min of management is superior to “standard” medical therapy, there are several reasons why the study findings are unlikely to be directly generalisable to UK practice: doctors are rare in the UK prehospital setting, as are the additional personnel reported here, and …