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www.elsevier.com/locate/ajem

American Journal of Emergency Medicine (2011) xx, xxx–xxx

YAJEM-52767; No of Pages 5

Brief Report

Noninvasive ventilation use in French out-of-hospitalsettings: a preliminary national surveyFrançois Templier MDa,⁎, Laetitia Labastire MDb, Philippe Pes MDb,Frédéric Berthier MDb, Philippe Le Conte MD, PhDb, Frédéric Thys MD, PhD c

aSAMU 92 – SMUR Garches, Raymond Poincaré Teaching Hospital, Assistance Publique, Hôpitaux de Paris,92380 Garches, FrancebSAMU 44 – SMUR Nantes, Hôtel Dieu Teaching Hospital, 44000 Nantes, FrancecEmergency Department, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, 200 Brussels, Belgium

Received 14 January 2011; revised 10 March 2011; accepted 22 March 2011

AbstractObjective: The objective of our study was to describe noninvasive ventilation (NIV) practices (pressuresupport ventilation and continuous positive airway pressure) in French out-of-hospital mobile intensivecare units (SMUR) and their compliance with national consensus guidelines.Method: Online inquiry into practices of NIV among managers of French SMURs. Analyzed datainclude types of NIV devices and use of NIV.Results: Upon 218 SMURs referenced within the SAMU de France database, 118 questionnaires (54%)were processed. Noninvasive ventilation equipment: 91% of the SMURs with at least one type of NIVdevice (continuous positive airway pressure only, 82%; pressure support ventilation only, 59%; both,50%) but frequently not with recommended devices. Use of NIV: for acute cardiogenic pulmonaryedema, practices were compliant with recommendations in 80% of cases, although there was still roomfor improvement. For other pathologies, practices were very heterogeneous, not always properlyassessed, and frequently not compliant with recommendations.Conclusion: To conclude, NIV use in the out-of-hospital setting in France seems to meet currentrecommendations for acute cardiogenic pulmonary edema but not for other pathologies. This could beimproved by the use of written procedures, conduction of further studies, and promotion of compliancethrough education.© 2011 Published by Elsevier Inc.

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1. Introduction

During the last 20 years, noninvasive ventilation (NIV)has proved to be beneficial in the treatment of acuterespiratory failure (ARF) in critical care units, thus reducingendotracheal intubation and mortality rates, and its in-

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⁎ Corresponding author. Tel.: +33 1 47 10 70 39; fax: +33 1 47 10 70 07.E-mail address: francois.templier@rpc.aphp.fr (F. Templier).

0735-6757/$ – see front matter © 2011 Published by Elsevier Inc.doi:10.1016/j.ajem.2011.03.012

dications have been optimized [1,2]. Concerning acutecardiogenic pulmonary edema (ACPE), the benefit ofcontinuous positive airway pressure (CPAP) is equivalentto that of pressure support ventilation (PSV) [3]. In acuteexacerbation of chronic obstructive pulmonary disease(COPD), PSV is recommended [4]. Noninvasive ventilationcould also be used with the do-not-intubate patients.

The use of NIV by emergency physicians has also shownto be of interest in ACPE and in ARF secondary to COPD[5,6]. Trained medical teams and appropriate equipment are

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Table 1t1:1 French specific recommendations for use of NIV in out-of-hospital and ED settings [2]t1:2t1:3 Pathology Recommended NIV mode and devices Level of recommendation (GRADE) [13]

t1:4 ACPE CPAP, with free-flow system devices Unquestionable value (G1+)—Should be donet1:5 or PSV only for well-trained teams owning

adequate respiratory ventilatorValue not established with certainty(G2+)—Should probably be done

t1:6 COPD PSV only for well-trained teams owningadequate respiratory ventilator

Value not established with certainty(G2+)—Should probably be done

2 F. Templier et al.

required. Nevertheless, an increased risk of death wasreported in the event of delayed intubation or noncomplianceto validated indications, highlighting the potential iatrogen-esis related to the use of the device without adequateexpertise [7].

The few published studies concerning out-of-hospital carefocus mainly on the feasibility, clinical benefits, and cost-benefit aspect of CPAP devices during ACPE [8-10]. Studiesusing PSV in the out-of-hospital environment are rare.However, a benefit for patients having ARF secondary toCOPD is expected [11]. In these studies, PSV failure rateswere similar to those performed at in-hospital level [12].Continuous positive airway pressure mode is considered assimple as PSV to use. Paramedics can be trained to useCPAP for patients in ACPE or with other severe respiratoryfailure [11].

In 2006, a French consensus meeting on NIV drew upsome recommendations, according to the GRADE grid [13].In the out-of-hospital setting, recommendations were to useCPAP mode to treat ACPE, with free-flow system devices.Pressure support ventilation use for the treatment of ARF inCOPD is strictly limited to trained teams with adaptedequipment (Table 1) [2]. Current practices in the use of NIVand compliance with the recommended guidelines have notbeen studied in France or in other countries. The objective ofour study was to describe NIV practices (NIV mode, CPAPor PSV; indications) in French SMURs at a national leveland their compliance with national consensus guidelines.

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2. Methods

In France, out-of-hospital life-threatening cases aremanaged by a medical team (emergency physician with anurse and a basic paramedic) from out-of-hospital mobileintensive care units (called SMUR), the latter beingcoordinated by an emergency medical call center (calledSAMU) [14]. The SMUR are located in hospital, and eachone has one or several medical teams.

In 2006, a standardized online questionnaire was sent to218 SMUR centers that were registered in SAMU de FranceDatabase. The SMUR medical directors were asked toanswer the following questions: (1) Available equipment:whether their transport units were equipped with NIVdevices and, if so, whether it was PSV ventilators and/or

CPAP devices; (2) Indication of NIV: description of the typeof NIV support (CPAP and/or PSV) that could be used andtheir estimated frequency of use according to the etiology:ACPE, acute exacerbation of COPD, hypercapnic ARFwithout COPD, hypoxemic without hypercapnic ARF, ARFin neuromuscular diseases, and ARF in selected “do-not-intubate” patients; (3) Available NIV procedure for themedical team.

This is a descriptive survey; the results are presentedin percentage.

3. Results

One hundred eighteen SMUR (54%) answered. Onehundred seven (91%) of them were equipped with NIVdevices. Ninety-six SMUR (81%) had access to a CPAPdevice, 69 (58%) to a PSV ventilator, with 58 (49%) havingaccess to both of them. Among the 96 SMUR that reportedhaving a device that could be used in CPAP mode, it wasavailable in every vehicle for 69 (72%) of them. Among the69 SMURs that reported having a ventilator that could beused in PSV mode, it was available in every vehicle for 37(54%) of them.

Two medical directors did not answer the questionnairesconcerning use of NIV. When NIV was available, SMURmedical directors declared using it for 100% of patientshaving ACPE and in 74% of cases for acute exacerbation ofCOPD. For other pathologies, NIV was used in about 50%or 60% of cases. Continuous positive airway pressure(exclusively) was more often used for ACPE (65%),whereas PSV was more often used for acute COPDexacerbation (43%) (Fig. 1).

Frequency of NIV use was well known for ACPE (97%).For other pathologies, it was less known (Fig. 2). In the caseof ACPE, NIV was used “always” or “frequently” in 75% ofSMURs. There was no answer declaring “never” using it inthis case. Noninvasive ventilation was used always orfrequently in 36% of SMURs for acute exacerbation ofCOPD and 21% for hypercapnic ARF without COPD. It wasnever used in, respectively, 15% and 24% of cases. For otherpathologies, NIV was rarely used (Fig. 2).

Only one third of the SMURs had a written procedureavailable for ACPE, 15% had one devoted to acuteexacerbation of COPD, and very rarely for other pathologies.

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Fig. 1 Noninvasive ventilation mode in percentage among different SMUR, having available NIV device according to pathologies asdeclared by SMUR medical directors (n = 105).

3NIV use in French out-of-hospital settings

4. Discussion

The prevalence of NIV use and compliance with nationalguidelines have not been previously well studied in the out-of-hospital setting [11]. Our study is the very first one thatdescribes NIV use (indication, mode) in daily practice in theout-of-hospital setting. Our survey shows heterogeneouspractice among different SMUR. Use of NIV and modechoice is variable according to pathologies and not always inaccordance with recommendations [2]. In addition, for manySMUR, devices are not always available in each ambulance,thus limiting its valid use.

For ACPE where CPAP has been shown to be highlyeffective, practices were, most of the time, compliant withrecommendations, although there was still room forimprovement. Firstly, for 20% of SMUR, use of NIV isstill rare. Secondly, 35% use PSV each time, although CPAPis recommended in out-of-hospital setting.

In case of acute COPD exacerbation in the out-of-hospitalsetting, one study showed that PSV used by trained

emergency physicians brings similar benefits to thosepracticed in the intensive care unit [12]; widespread usewas approved by the French consensus conference, but withsome reservations: this should be performed only by skilledand trained teams owning adequate respiratory ventilator. Itsmisuse may increase mortality rate [7]. Despite theselimitations, our study showed a regular use of PSV bysome SMUR without any information about the level oftraining of the SMUR teams, the devices' performance,patient mortality, or complications. In one third of the cases,CPAP was used, although it was not recommended in thatcase [2].

For do-not-intubate patients, NIV is rarely used,although it could bring an added value [15]. For otherpathologies, practices were very heterogeneous, notalways properly assessed, and frequently not compliantwith recommendations.

The lack of available written procedures could explain thefrequency of “out-of-recommendations” use of NIV for low-prevalence pathologies.

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Fig. 2 Frequency of NIV use in percentage among different SMUR, having available NIV device according to pathologies as declared bySMUR medical directors (n = 105).

4 F. Templier et al.

Our study has other limitations. It is based on SMURmedical directors' declaration, and actual practice is notevaluated here. A declarative method always allows a likelypart of subjectivity, and SMUR medical directors were notable to assess the practices of their medical teams in 17%(COPD) and 30% to 40% (other pathologies) of cases (Fig. 2).However, our aim was to make a preliminary description ofthe use of NIV in out-of-hospital setting in France. We chosethe simplest method to show general trends. In addition, therewas no information on patient outcome and complicationsreported in this study. In the future, it would be important toset up an observational survey with more precise evaluation.This study is also limited to French practice and may notnecessarily be extrapolated to other countries. Assessment ofout-of-hospital NIV practices in other countries with para-medics or medical out-of-hospital emergency system wouldalso bring interesting information.

To conclude, NIV use in the out-of-hospital setting inFrance seems to meet current recommendations for ACPEbut not for other pathologies. This could be improved by theuse of written procedures, conduction of further studies, andpromotion of compliance through education.

Acknowledgment

The authors thank Anna Ozguler, Thierry Lentz, andMaidei Gugu Kabayadondo for assistance with languageediting and SAMU de France for making available itsdatabase.

Statement of interest: None declared

References

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[2] Robert R, Bengler C, Beuret P et al. Consensus conference on non-invasive positive-pressure ventilation in acute respiratory failure(excluding newborn infants): long text. Common consensus confer-ence of the Societe de Reanimation de Langue Francaise, the Societe

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[3] Masip J. Noninvasive ventilation in acute cardiogenic pulmonaryedema. Curr Opin Crit Care 2008;14:531-5.

[4] Ram FS, Picot J, Lightowler J, et al. Non-invasive positive pressureventilation for treatment of respiratory failure due to exacerbations ofchronic obstructive pulmonary disease. Cochrane Database Syst Rev2004;3:CD004104.

[5] Thys F, Roeseler J, Reynaert M, et al. Noninvasive ventilation foracute respiratory failure: a prospective randomised placebo-controlledtrial. Eur Respir J 2002;20:545.

[6] Collins SP, Mielniczuk LM, Whittingham HA, et al. The use of non-invasive ventilation in emergency department patients with acutecardiogenic pulmonary edema: a systematic review. Ann Emerg Med2006;48:260-269.e4.

[7] Wood KA, Lewis L, Von Harz B, et al. The use of noninvasive positivepressure ventilation in the emergency department: results of arandomized clinical trial. Chest 1998;113:1339-46.

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[10] Hubble MW, Richards ME, Wilfong DA. Estimates of cost-effectiveness of prehospital continuous positive airway pressure inthe management of acute pulmonary edema. Prehosp Emerg Care2008;12(3):277-85.

[11] Thys F, Spencer S, Verschuren F, et al. NIV: use during the pre-hospital management of patients with acute respiratory failure. EurRespir Mon 2008;41:133-42.

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[15] Duchateau FX, Beaune S, Ricard-Hibon A, et al. Prehospitalnoninvasive ventilation can help in management of patients withlimitations of life-sustaining treatments. Eur J EmergMed 2010;17:7-9.

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