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1 From the Department of Internal Medicine, Pulmonary and Critical Care Division, and Department of Emergency Medicine, Washington University School of Medicine, Department of Respiratory Care Services, Barnes-Jewish Hospital, St. Louis
Objective: To determine whether the use of noninvasive positive pressure ventilation (NPPV) in the emergency department (ED) will reduce the need for tracheal intubation and mechanical ventilation.
Design: Randomized, controlled, prospective clinical trial.
Setting: ED of Barnes-Jewish Hospital, a university-affiliated teaching hospital.
Patients: Twenty-seven patients meeting a predetermined definition of acute respiratory distress requiring hospital admission.
Interventions: Conventional medical therapy for the various etiologies of acute respiratory distress and the application of NPPV.
Measurements and results: The primary outcome measure was the need for tracheal intubation and mechanical ventilation. Secondary outcomes also assessed included hospital mortality, hospital length of stay, acquired organ system derangements, and the utilization of respiratory care personnel. Sixteen patients (59.3%) were randomly assigned to receive conventional medical therapy plus NPPV, and 11 patients (40.7%) were randomly assigned to receive conventional medical therapy without NPPV. The two groups were similar at the time of randomization in the ED with regard to demographic characteristics, hospital admission diagnoses, and severity of illness. Tracheal intubation and mechanical ventilation was required in seven patients (43.8%) receiving conventional medical therapy plus NPPV and in five patients (45.5%) receiving conventional medical therapy alone (relative risk=0.96; 95% confidence interval=0.41 to 2.26; p=0.930). There was a trend towards a greater hospital mortality rate among patients in the NPPV group (25%) compared to patients in the conventional medical therapy group (0.0%) (p=0.123). Among patients who subsequentiy required mechanical ventilation, those in the NPPV group had a longer time interval from ED arrival to the start of mechanical ventilation compared to patients in the conventional medical therapy group (26.0±27.0 h vs 4.8±6.9 h; p=0.055).
Conclusions: We conclude that the application of NPPV in the ED may delay tracheal intubation and the initiation of mechanical ventilation in some patients with acute respiratory distress. We also demonstrated that the application of NPPV was associated with an increased hospital mortality rate. Based on these preliminary observations, larger clinical investigations are required to determine if adverse patient outcomes can be attributed to the early application of NPPV in the ED. Additionally, improved patient selection criteria for the optimal administration of NPPV in the ED need to be developed.
Key Words: acute respiratory failure • critical care • mechanical ventilation • noninvasive positive pressure ventilation • outcomes
Submitted on August 20, 1997
Accepted on October 31, 1997
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