Nghiên cứu áp dụng kỹ thuật thông khí áp lực dương liên tục boussignac (CPAP b) trong xử trí trước bệnh viện khó thở cấp cứu luan án tom tat (english)

MINISTRY OF EDUCATION & TRAINING MINISTRY OF NATIONAL DEFENCE 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES - NGUYỄN THÀNH APPLICATION STUDY OF CONTINUOUS POSITIVE AIRWAY PRESSURE BOUSSIGNAC (CPAP-B) FOR EMERGENCY DYSPNEA IN PRE-HOSPITAL SETTING Specialty: Anesthesia – Critical care Code: 62720122 DISSERTATION SUMMARY Name of supervisors: Professor VŨ VĂN ĐÍNH Professor LÊ ANH TUẤN PhD Hà Nội – 2018 THIS DISSERTATION WAS FULFILLED AT 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES Name of supervisors: Professor VŨ VĂN ĐÍNH Professor LÊ ANH TUẤN PhD Reviewer 1: …………………………………………………… Reviewer 2: …………………………………………………… Reviewer 3: …………………………………………………… This Dissertation will be defended in front of Dissertation committee of the Institute at: date: / / This Dissertation can be found at: National Library Library of 108 Institute of clinical medical and pharmaceutical sciences RATIONAL AND JUSTIFICATION Emergency dyspnea is a common pathologic presentation in prehospital setting, about 25% of total cases on ambulances [18] This may be a sign of life threatening condition, especially with warning signs such as altered mental status, respiratory failure, unstable hemodynamic [9] General principles for approaching patient with emergency dyspnea include: Airway management, breathing support, circulation support Non-invasive ventilation, BiPAP, CPAP can be choices for emergency dyspnea patients with respiratory failure [5] CPAP Boussignac (CPAP-B) is a non-invasive ventilation device it can generate continuous positive airway pressure which increase alveoli ventilation and oxygenation This is a simple, light weight, portable device that is convenient for using on ambulances [4] and it has been applied in pre-hospital setting in many countries with positive outcomes In Vietnam, no study on this device in pre-hospital care for patients with emergency dyspnea is found Objectives Surveillance clinical presentation, arterial blood gas of patients with emergency dyspnea in pre-hospital setting Evaluation the effectiveness of Continuous Positive Airway Pressure Boussignac (CPAP-B) for patients with emergency dyspnea in pre-hospital setting Evaluation undesired effects during application of CPAP-B CHAPTER LITERATURE REVIEW 1.1 Emergency dyspnea 1.1.1 Concept of emergency dyspnea Emergency dyspnea is defined as the newly onset or acute on chronic of uncomfortable breathing arising within 24 to 48 hours and accompanied by “warning signs” such as:  Airway obstruction: wheezing, foreign body in the airway  Respiratory failure, hypoxia, altered mental status, difficult speaking, using accessory muscles, respiratory muscles fatigue, tachypnea, pursed lips, diminishing breath sound one or both sides  Unstable hemodynamic: chest pain, tachycardia, hypotension  Reduced oxygen saturation [16,18] Those warning signs along with emergency dyspnea required immediate critical interventions for saving patient’s life, and those signs are also significant for making diagnosis [26] 1.1.2 Principle of emergency dyspnea management in the prehospital setting Emergency dyspnea is a life-threatening situation, in the context of pre-hospital care, Management of cases with emergency dyspnea focus to airway assessment, breathing and circulation support in order to secure patient life and safe transport to hospitals 1.2 CPAP Boussignac (CPAP-B) 1.2.1 Mechanism of action CPAP-B is a non-invasive ventilation support device It generates airway continuous positive pressure from oxygen flow That helps improve alveoli ventilation and oxygenation Mechanism of action of CPAP-B is based on principle of Bernoulli The air flow from a larger diameter pipe to a smaller diameter one is accelerated to the speed of sound The interference of those air flow within Boussignac valve creates a turbulent flow which in turn working as a virtual valve generates positive pressure toward patients 1.2.2 Indication: Acute respiratory failure because of [24] - Acute pulmonary edema - Post-operation patients - Chest wall trauma - Support ETT intubation - Pneumonia - Support Weaning - Acute COPD exacerbation - Asthma attack - Sleep apnea 1.2.3 Contraindication: [24] - Cardiac arrest - Active vomiting, aspiration risk - Apnea - Face burn, trauma - Unconscious - ENT, face active bleeding - Systolic pressure < 90 mm Hg - Pneumothorax - Serious Chest trauma - Skull base fracture - Agitation, un-cooperation - Dyspnea due to neuro- - Inability to protect airway - Profuse secretion or coughing muscular conditions inability 1.2.4 Effectiveness of CPAP-B for management respiratory failure in the prehospital setting Templier studied 57 patients with acute pulmonary edema those who were applied CPAP-B in pre-hospital setting The result shown that this device helped improving respiratory rate and SpO2 significantly [29] D.T Wong revealed that CPAP-B helped not only improving SpO2 and respiratory rate significantly but also reduced intubation rate down to 20% [31] Research of Eva Eiske Spijker et al gave similar positive results [19] Thomas Luiz (2016) applied CPAP-B for 57 patients with respiratory failure in the pre-hospital setting, including of 35 patients with acute pulmonary edema and 22 patients with COPD The result revealed that respiratory rate, oxygenation was improved similarly between two group but the intubation rate in acute pulmonary edema group was higher than COPD group (17.1% vs 4.5%) [30] This result was similar to a study of Willi Schmidbauer 2010 [27] In Vietnam, up to date, There is no research on the effectiveness of CPAP-B applying on ambulances or in the pre-hospital setting 1.2.5 Undesired effects of CPAP Boussignac Since 2009, John Bosomworth had found some undesired effects of CPAP-B such as: - Pain or ulcer over the nasal bridge - Mucosal dryness - Pneumothorax (very rare) - Fear of closed space - Aspiration or gastric insufflation (rare) - Eye irritation However this author did not mention which side effect was the most common as well as the rate of each side effect or what kind of patient with what kind of problem [24] Eva Eiske Spijker (2013) conducted a study to assess effectiveness and related complication of CPAP-B when applying for patients with acute pulmonary edema in the pre-hospital setting The result shown that this device was safe and had no complication [19] Similarly, Thomas Luiz et al (2016) announced that “CPAP-B can be used safely and effectively in the prehospital setting for patients who suffering from acute pulmonary edema and COPD” [30] CHAPTER METHODOLOGY 2.1 Target population All patients with emergency dyspnea, those who were provided prehospital care and transported to hospital by 115 Hanoi Emergency Center from January 2015 to December 2015 2.1.1 Eligible criteria Patient was recruited to this research when they had newly onset or acute on chronic of dyspnea arising within 24 to 48 hours and accompanied by at least one of following symptom:  Unstable hemodynamic: chest pain, tachycardia, hypotension  Reduced oxygen saturation [16,18]  Tachypnea with respiratory rate ≥ 25 breath/min; or accessory muscle breathing or paradoxical abdominal movements  Cyanosis; or SpO2 < 95 %  Tachycardia: heart rate > 100 beat/min AND SpO2 < 95 % after minutes on oxygen therapy with liter per minute via face mask or nasal cannula 2.1.2 Exclusion criteria Any patient with at least one of following criteria:  age < 18  uncooperative patients  contraindication with non-invasive ventilation  Pneumothorax without chest decompression  Open chest injury  Abnormal or any trauma of facial structure  Foreign body of upper airway is suspected  Systolic Blood pressure < 90 mmHg  Respiratory rate 20%  Stable hemodynamic  Respiratory rate < 25 breath/min  Improving clinical signs and symptoms [3,7] Failure criteria (one or more of following)  Worsen respiratory failure lead to termination of therapy and deploying other methods for breathing support such as intubation, laryngeal mask airway, AMBU  Unstable hemodynamic  SpO2 < 95% with CPAP level up to 10 cm water  Uncooperation or appearance of related complications lead to termination of therapy[3,7] 2.3 Statistical analysis Data was analyzed by medical statistic methods Mean, standard diviation was performed as X ± SD (standard distribution) or as median, quartile (non-standard distribution) Percentage was compared by χ2 test (or Fisher test) Mean of two independent groups were compaired by t - test (standard distribution) or Mann-Whitney test (non-standard distribution) Paired-t-test (standard distribution) or Wilcoxon (non-standard distribution) was used for before – after comparison One way ANOVA test (standard distribution) and Kruskal-Wallis test (non-standard distribution) was for comparison of multiple means p value < 0,05 was consider statistical significance 11 Table 3.10 Accessory muscle breathing Accessory muscle breathing n Percentage Yes 144 96 % No 4% 150 100 % Total Comment: Most of patients had sign of accessory muscle breathing Table 3.11 Level of clinical respiratory failure Clinical respiratory failure n Percentage Level I 10 6.7 % Level II 110 73.3 % Level III 30 20.0 % Level IV 0.0 % 150 100 % Total Comment: All patients with emergency dyspnea had respiratory failure clinically at different level, mostly level II (73.3%) 3.2.2 Vital signs of patients with emergency dyspnea Table 3.13 Pre-intervention vital signs ̅ ± SD) Vital signs (𝐗 Min Max 125.2 ± 12.0 90 156 Respiratory rate (breath/min) 32.5 ± 5.3 20 56 SPO2 (%) 71.6 ± 8.1 46 86 Systolic BP (mmHg) 141.9 ± 36.6 90 250 Diastolic BP (mmHg) 81.1 ± 16.1 40 140 Heart rate (beat/min) Comment: Before intervention, heart rate, respiratory rate, blood pressure increased, SpO2 decreased 12 3.2.3 Arterial blood gas of patients with emergency dyspnea Table 3.14 Pre-intervention arterial blood gas ̅ ± SD) ABG n (𝐗 Min Max PaO2 (mmHg) 150 60.98 ± 10.14 38.00 79.70 PaCO2 (mmHg) 150 44.51 ± 13.55 20.10 82.20 HCO3 (mmol/L) 150 24.65 ± 4.84 13.20 37.10 Comment: PaO2 decreased, PaCO2 was at upper level of normal range Table 3.15 Pre-intervention acid-base balance pH n Percentage 7.45 48 32 % Total 150 100 % Comment: 62% patients had acid-base imbalance prior intervention 3.3 Effectiveness of CPAP Boussignac in pre-hospital emergency dyspnea management 3.3.1 Clinical changes before and after intervention p