Non-invasive mechanical ventilation in Australian emergency departments: A prospective observational cohort study

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Abstract

Objectives

Data describing use of non-invasive ventilation (NIV) in the emergency department (ED) setting consist primarily of physician surveys. Our objective was to conduct a prospective study to document the characteristics of patients receiving NIV, interfaces, mode, and parameters used as well as NIV duration and decision-making responsibility.

Methods

We conducted a 2-month prospective observational study of adult patients who received NIV in 24 EDs. Patient characteristics, delivery methods, and decision-making responsibility were documented for each ED presentation.

Results

Data were recorded on 245 patients; 185 patients received non-invasive positive pressure ventilation (NIPPV) and 60 received continuous positive airway pressure (CPAP). Acute cardiogenic pulmonary oedema (ACPO) (80/245, 33%) and exacerbation of chronic obstructive pulmonary disease (COPD) (75/245, 31%) were the two most frequent indications for NIV. Compared to patients with respiratory failure from other aetiologies, those with ACPO were more likely to receive CPAP (28/80 [35%] versus 32/165 [19%] P = 0.008). Initial NIV settings were selected by ED nurses for 118/245 (48%) patients, by ED physicians for 118/245 (48%) patients, and by ICU staff for 3/245 (1.5%) patients (not reported for 6 [2.5%] patients). The role of ED nurses in the selection of initial NIV settings was not influenced by ED location, patient type or triage category.

Conclusions

Acute exacerbations of CPO and COPD were the most common indications for NIV. Clinicians demonstrated a preference for NIPPV for all patient aetiologies except ACPO. Responsibility for NIV management was shared by ED nurses and physicians.

Introduction

Non-invasive ventilation (NIV) describes the delivery of mechanical ventilation without the use of an invasive artificial airway for the management of acute respiratory failure arising from various aetiologies. NIV is further categorised as non-invasive positive pressure ventilation (NIPPV) and continuous positive airway pressure (CPAP). NIPPV is the provision of inspiratory pressure support (also referred to as inspiratory positive airway pressure [IPAP]) plus positive end expiratory pressure (PEEP) (also referred to as expiratory positive airway pressure [EPAP]) via a mask interface. Biphasic positive airway pressure (BiPAP®) (Respironics, Murrayville, PA), Bilevel, and non-invasive pressure support ventilation (NIPSV) are terms also used to describe NIPPV. CPAP provides a constant positive airway pressure throughout inspiration and expiration.

Strong evidence supports NIV use as an adjunct to standard treatment for the management of acute cardiogenic pulmonary oedema (ACPO) (Peter et al., 2006, Winck et al., 2006) and exacerbation of chronic obstructive pulmonary disease (COPD) particularly when implemented early (Keenan et al., 2003, Ram et al., 2004). Evidence supporting the role of NIV in patients with hypoxaemic respiratory failure due to causes other than ACPO and COPD is limited and has produced conflicting results (Hill et al., 2007).

Reports of NIV use in emergency departments (EDs) consists mainly of postal surveys sent to ED directors (Browning et al., 2006, Vanpee et al., 2002), emergency medicine physicians (Burns et al., 2005), or single centre observational studies (Antro et al., 2005). The provision of NIV in the ED varies at both local and international levels. A survey of Belgian EDs identified only 49% used NIV (Vanpee et al., 2002); in the United Kingdom 67% of surveyed EDs reported using NIV, though 61% of EDs not using NIV planned to do so in the future (Browning et al., 2006). Anecdotally, NIV use in Australian EDs is high (Browning et al., 2006) however there is no empirical data to describe its use. As well there is no data describing the role of the ED nurse in the management of NIV, which this study aimed to redress. To assess compliance with recommendations made in existing NIV guidelines (British Thoracic Society Standards of Care Committee, 2002, Evans, 2001), the objective of the present study was to document the use of NIV in the Australian ED setting including (1) the characteristics of patients receiving NIV; (2) the interfaces, parameters and duration of NIV and; (3) the decision-making responsibility for management of NIV. A secondary objective was to compare the characteristics of patients receiving NIPPV and CPAP.

Section snippets

Study design and setting

We conducted a 2-month prospective observational cohort study in early 2007 of all adult patients who received NIV in 24 Australian EDs. Data forms were completed by nursing staff during the patient's ED presentation. Expressions of interest to participate were extended to all contributors to the Victorian Emergency Minimal Dataset (n = 30) (Department of Human Services, 2008) facilitated via the College of Emergency Nursing Australasia (CENA) nurse manager group. To provide representation across

Demographic characteristics

During the study period, data were recorded on 245 patients who received NIV in the 24 participating EDs. EDs vary widely in size and capacity from large metropolitan principal referral services through to regional and small remote area acute care services. Eleven of the 24 participating EDs (46%) were classified as principal referral services (17% of all Australian EDs thus classified) (Australian Institute of Health and Welfare, 2007), 3/24 were located in major cities (not classified as

Discussion

This prospective study conducted in Australian EDs found NIV was predominantly used for patients with acute exacerbation of ACPO and COPD, consistent with recommended practice (Evans, 2001). Three published meta-analyses have shown a reduction in intubation rates, hospital length of stay and mortality with the use of NIV for COPD patients (Keenan et al., 2003, Lightowler et al., 2003, Ram et al., 2004). Comparable findings have been demonstrated with the early use of NIV in combination with

Conclusion

This prospective survey of NIV use in Australian EDs identified practice consistent with current international recommendations and best evidence. Acute exacerbations of CPO and COPD were the most frequent indications for NIV. Clinicians demonstrated a preference for NIPPV for all patient aetiologies except ACPO. Overall NIV management was shared between physicians and nursing staff across ED classifications and locations. To facilitate safe delivery of NIV in the ED these findings may be used

Conflict of interest

The views expressed in this manuscript do not necessarily represent those of the Nurses Board of Victoria. The authors have no potentially conflicting interests to declare.

Funding

This study was supported by a Major Research Grant from the Nurses Board of Victoria.

Ethics approval

Ethics approval was given by RMIT University and all participating sites. SETAPP 46-06.

Acknowledgements

The authors thank the College of Emergency Nursing Australasia (CENA) for assisting with the site recruitment. In addition, the authors thank Dr. Kat Pawley for assistance with data entry and Kathryn Bowman for assisting with the pilot data collection.

The authors also thank the following study coordinators at each of the above named sites.

Brooke Alexander, Leanne Smith, Jacqui Allen, Heather Steen, Natalie Jones, Darren Jacob, Wendy Porteous, Jennifer Oxley, Michelle Grummisch, Barbara Harper,

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    This study was based upon survey results from the emergency departments in the following Australian hospitals: State of Victoria: The Alfred Hospital, The Angliss Hospital, Bairnsdale Hospital, Ballarat Base Hospital, Bendigo Health, Box Hill Hospital, Central Gippsland Health Service, East Wimmera Health Service, Goulburn Valley Health, Mildura Base Hospital, The Northern Hospital, The Royal Melbourne Hospital, St Vincent's Hospital; State of New South Wales: Canterbury Hospital, Manly Hospital, Mona Vale Hospital, The Prince of Wales Hospital, St Vincent's Hospital, Tamworth Hospital, Wollongong Hospital; State of Western Australia: Kalgoorlie Hospital; State of Queensland: Nambour Hospital; State of South Australia: The Royal Adelaide Hospital; State of Tasmania: The Royal Hobart Hospital.

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