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Prehospital continuous positive airway pressure (CPAP) for acute respiratory distress: a randomised controlled trial
  1. Judith C Finn1,2,
  2. Deon Brink1,2,
  3. Nicole Mckenzie1,3,
  4. Antony Garcia2,
  5. Hideo Tohira1,4,
  6. Gavin D Perkins5,
  7. Glenn Arendts4,6,
  8. Daniel M Fatovich4,7,
  9. Delia Hendrie8,
  10. Brendan McQuillan4,9,
  11. Quentin Summers10,
  12. Antonio Celenza4,11,
  13. Ashes Mukherjee12,
  14. Ben Smedley13,
  15. Gavin Pereira8,
  16. Stephen Ball1,2,
  17. Teresa Williams3,
  18. Paul Bailey1,2
  1. 1Prehospital, Resuscitation, and Emergency Care Research Unit (PRECRU), Curtin University, Perth, Western Australia, Australia
  2. 2St John Western Australia, Perth, Western Australia, Australia
  3. 3Critical Care Division, Royal Perth Hospital, Perth, Western Australia, Australia
  4. 4School of Medicine, The University of Western Australia, Perth, Western Australia, Australia
  5. 5Warwick Medical School, University of Warwick, Coventry, West Midlands, UK
  6. 6Emergency Department, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
  7. 7Centre for Clinical Research in Emergency Medicine, Royal Perth Hospital, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia
  8. 8School of Public Health, Curtin University, Perth, Western Australia, Australia
  9. 9Department of Cardiovascular Medicine, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
  10. 10Respiratory Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
  11. 11Emergency Department, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
  12. 12Emergency Department, Armadale Kelmscott District Memorial Hospital, Armadale, Western Australia, Australia
  13. 13Emergency Department, Rockingham General Hospital, Cooloongup, Western Australia, Australia
  1. Correspondence to Professor Judith C Finn, Prehospital, Resuscitation, and Emergency Care Research Unit (PRECRU), Curtin University, Perth, WA 6102, Australia; judith.finn{at}


Objective To compare the efficacy of continuous positive airway pressure (CPAP) versus usual care for prehospital patients with severe respiratory distress.

Methods We conducted a parallel group, individual patient, non-blinded randomised controlled trial in Western Australia between March 2016 and December 2018. Eligible patients were aged ≥40 years with acute severe respiratory distress of non-traumatic origin and unresponsive to initial treatments by emergency medical service (EMS) paramedics. Patients were randomised (1:1) to usual care or usual care plus CPAP. The primary outcomes were change in dyspnoea score and change in RR at ED arrival, and hospital length of stay.

Results 708 patients were randomly assigned (opaque sealed envelope) to usual care (n=346) or CPAP (n=362). Compared with usual care, patients randomised to CPAP had a greater reduction in dyspnoea scores (usual care −1.0, IQR −3.0 to 0.0 vs CPAP −3.5, IQR −5.2 to −2.0), median difference −2.0 (95% CI −2.5 to −1.6); and RR (usual care −4.0, IQR −9.0 to 0.0 min-1 vs CPAP −8.0, IQR −14.0 to −4.0 min-1), median difference −4.0 (95% CI −5.0 to −4.0) min-1. There was no difference in hospital length of stay (usual care 4.2, IQR 2.1 to 7.8 days vs CPAP 4.8, IQR 2.5 to 7.9 days) for the n=624 cases admitted to hospital, median difference 0.36 (95% CI −0.17 to 0.90).

Conclusions The use of prehospital CPAP by EMS paramedics reduced dyspnoea and tachypnoea in patients with acute respiratory distress but did not impact hospital length of stay.

Trial registration number ACTRN12615001180505.

  • prehospital care
  • clinical management
  • respiratory
  • ventilation
  • non invasive
  • respiratory
  • COPD

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  • Handling editor Caroline Leech

  • Twitter @judith_finn, @CCREM2, @EM_VATA

  • Contributors TW and DB were responsible for identifying the research question and TW drafted the initial study protocol for the randomised controlled trial (RCT). TW, JF, GA, DF, BM, GDP, DH, PB, QS and DB contributed to further development of the RCT study protocol and were all listed as investigators on the (successful) grant application for funding for the in-hospital follow-up. TW and DB undertook the training of the paramedics who volunteered to participate in the study. DB, PB and AG oversaw the conduct of the prehospital RCT and AG collected the ambulance data. GA, DF, AC, AM and BS enabled access for the in-hospital patient follow-up, which was undertaken by NM. GP undertook the interim analysis and subsequently advised on the statistical methods for the final analyses. HT analysed the data and produced the tables and figures. All authors contributed to data interpretation. JF was responsible for drafting the article. All authors provided comments on the drafts, read and approved the final version of the article. JF takes responsibility for the paper as a whole. All authors attest to meeting the four authorship criteria: (1) substantial contributions to the conception or design of the work; or the acquisition, analysis or interpretation of data for the work; and (2) drafting the work or revising it critically for important intellectual content; and (3) final approval of the version to be published; and (4) agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Funding Western Australian Department of Health, State Health Research Advisory Council (SHRAC) Research Translation Project funding—RTP2016R10. There was no external funding of the prehospital RCT—it was supported collaboratively by St John Western Australia and PRECRU at Curtin University. Funding for the in-hospital follow-up was provided by the Western Australian Department of Health, State Health Research Advisory Council (SHRAC) Research Translation Project funding. The funder of the study had no role in study design, data collection, data analysis, data interpretation or writing of the report; nor did the manufacturer of the CPAP masks.

  • Competing interests Several of the authors are affiliated with St John Western Australia, as follows: DB, AG, PB (employees); JF, SB (adjunct research positions); JF (research funding).

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No data are available. Current ethics approvals do not include sharing of individual patient data. However, it may be possible to share aggregated results on reasonable request.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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