In EMS, we must always be careful about making grandiose claims. However, I don’t think it’s going too far to say that in Houston, CPAP is revolutionizing patient care, from reducing intubations to improving the rate of patient recovery, all while reducing costs.
In a supplement in the October 2007 JEMS, I co-authored an article about a CPAP partnership between the Houston Fire Department (HFD) EMS and the Memorial Hermann Healthcare System. In that article, Michael Hewitt and I pointed out several advantages of CPAP in the EMS setting: from the clinical advantages of potentially reducing the short-term mortality of acute pulmonary edema and avoiding intubation, to the financial benefits of cost avoidance to the patient and the hospital by reducing ICU admissions and lengths of stay.
The evidence continues to mount. From April 1, 2005, through March 31, 2007, the two years prior to the implementation of CPAP within our department, HFD paramedics intubated 3,279 patients, or about 4.5 patients per day.
In the past two years since the HFD has been using CPAP (April 1, 2007, through March 31, 2009), paramedics have intubated 2,719 patients. This amounts to just 3.7 intubations per day on average.
These same paramedics have also used the CPAP device 1,173 times on patients during the same period, or an average of 1.6 times per day. An additional 10 patients had CPAP initiated by paramedics, but failed the therapy and were subsequently intubated in the field.
These data suggest that if the rate of intubation in Houston had remained constant, about half the time HFD paramedics used CPAP, they avoided an EMS intubation. An unknown number of other patients also did not require intubation in the ED or ICU.
With these data, we can safely assume the addition of CPAP to the armamentarium of paramedics has saved lives in this community. How can we make such an assumption? If for no other reason, we can make the assumption because of the avoidance of a pathologic process that few paramedics ever see or hear about—ventilator associated pneumonia (VAP).
A recent meta-analysis of the medical peer-reviewed literature demonstrated that the use of CPAP reduced the need for intubation as compared with standard therapy with a relative risk of 0.59.(1) By definition, VAP develops 48 hours or more after a patient has been on a ventilator. It complicates the course of approximately 28% of ventilated patients; more significantly, about 27% of those who develop VAP will succumb to it. (2,3) Some studies have documented mortality rates as high as 65%.(4)
The Centers for Disease Control and Prevention reports VAP has accounted for approximately 15% of all hospital-associated infections and 27% and 24% of all infections acquired in the medical ICU and coronary care unit, respectively. The CDC also reports that patients receiving continuous mechanical ventilation have six to 21 times the risk of developing hospital-associated pneumonia compared with patients who were not receiving mechanical ventilation.
The pathogenesis of ventilator-associated pneumonia probably involves the aspiration of oropharyngeal or gastric secretions. This being the case, with HFD potentially avoiding hundreds of field intubations per year and an unknown number of intubations in the ED and ICU, lives have been saved not just by the use of CPAP, but also by avoiding lethal cases of VAP.
Financial benefits have been realized as well. In a recent study, mean billed hospital charges were significantly greater for patients with VAP ($104,983 ± $91,080 vs. $63,689 ± $75,030, respectively; p < 0.001) compared to patients without VAP.(5)
These data emphasize the benefits CPAP provides our EMS and hospital systems and, most importantly, our patients.
Disclosure: The author has reported no conflicts of interest with the sponsor of this supplement.
- Peter JV, Moran JL, Phillips-Hughes J, et al: "Effect of non-invasive positive pressure ventilation (NIPPV) on mortality in patients with acute cardiogenic pulmonary edema: A meta-analysis." Lancet. 367(9517):1155–1163, 2006.
- Cook DJ, Walter SD, Cook RJ, et al: "Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients." Annals of Internal Medicine. 129(6):433–440, 1998.
- Collard HR, Saint S, Matthay MA: "Prevention of ventilator-associated pneumonia: An evidence-based systematic review." Annals of Internal Medicine. 138(6):494-501, 2003.
- Kollef MH, Silver P, Murphy DM, et al: "The effect of late-onset ventilator-associated pneumonia in determining patient mortality." Chest. 108(6):1655–1662, 1995.
- Rello J, Ollendorf DA, Oster G, et al (VAP Outcomes Scientific Advisory Group): "Epidemiology and outcomes of ventilator-associated pneumonia in a large US database." Chest. 122(6):2115–2121, 2002.