Focus on Respiration

   At this year's EMS State of the Sciences Conference, organizers grouped a handful of breathing-themed presentations under a theme of "evolving considerations in respiratory support." Its concepts included:

Does CPAP help prevent drug-assisted intubation?

   Prehospital CPAP seems to help prevent intubation. A small study in Nova Scotia a few years back linked CPAP for patients in severe respiratory failure to a 30% reduction in the number needing intubation. Using it in Houston reduced fire department intubations from 4.5 to 3.7 a day. In Portland, this prompted leaders to wonder if CPAP could help limit drug-facilitated intubations. The Multnomah County system had been using it since 2008 on qualified respiratory-distress patients. They reviewed data for drug-facilitated intubations from 2006-10 and found, among those patients, post-CPAP decreases in patients presenting with respiratory distress secondary to congestive heart failure and/or COPD. The effect was greatest on those presenting with CHF.

The impact of CPAP on physiologic improvement

   With a presence in 38 states amassing three million patient contacts a year, AMR surely generates data. All those reports made it a fertile place to study the impact of CPAP on physiologic improvement. New Chief Medical Officer Ed Racht, MD, had nearly 61,000 records at his disposal for the task.

   Just 2.2% of those patients received CPAP, but that's still 1,311 patients. And yes, they improved: More than 52% experienced improvements in their Rapid Acute Physiology Scores. RAPS is a scale that uses routinely available measures like pulse, BP, respiratory rate and GCS to gauge patients' severity. It's pretty good at predicting mortality. Of patients who didn't get CPAP, 37% had increases. A fifth of CPAP patients actually had improvements of 3 or more on their RAPS (the scale runs from 0-16), vs. 12% of those without.

Using EMT-Bs to treat asthma patients

   EpiPens came to FDNY's BLS ambulances two years ago to better treat patients in anaphylactic shock. But what about asthma? Department leaders knew from a previous study that EMT-Bs could effectively give those patients albuterol, but epi comes with higher stakes.

   It had proven pretty safe for ALS use: On 235 patients over 12 months, according to FDNY Medical Director John Freese, MD, it decreased heart rate and blood pressure, and allowed BVM ventilation to be discontinued on a third of the patients. A single death was reported. So starting April 1, 2010, a new protocol let FDNY Basics deliver a single 0.3 mg dose of epi post-albuterol to patients under 33 in severe respiratory distress or shock. The effort has been so successful, FDNY is now eyeing expanding use of its auto-injectors and dispatching BLS to all calls of asthma exacerbation.