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Trang chủ Nghiên cứu áp dụng kỹ thuật thông khí áp lực dương liên tục boussignac (cpap b) ...

Tài liệu 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)

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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: 1. Professor VŨ VĂN ĐÍNH 2. Professor LÊ ANH TUẤN PhD. Hà Nội – 2018 THIS DISSERTATION WAS FULFILLED AT 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES Name of supervisors: 1. Professor VŨ VĂN ĐÍNH 2. 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: 1. National Library 2. Library of 108 Institute of clinical medical and pharmaceutical sciences 1 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 1. Surveillance clinical presentation, arterial blood gas of patients with emergency dyspnea in pre-hospital setting 2. Evaluation the effectiveness of Continuous Positive Airway Pressure Boussignac (CPAP-B) for patients with emergency dyspnea in pre-hospital setting 3. Evaluation undesired effects during application of CPAP-B 2 CHAPTER 1 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 3 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]. 4 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]. 5 CHAPTER 2 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 5 minutes on oxygen therapy with 5 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 <10 breath/min  Glasgow score < 8 or at U level (on AVPU scale) 6 2.2. Methodology 2.2.1. Research design: prospective interventional study 2.2.2. Sample size Sample size was estimated according to the following formula : n 2  C  (1  r ) 2  19,84  1  0,6   142,87  150 0,3333 2 ES 2 C : constant; C = 19,84 with  = 0,01;  = 0,05 r : relative risk, estimated equal 0,6 ES: Effect size: ES = d /s d was average difference of SpO2 before and after intervention (estimated 5%), s was standard deviation (estimated 5%) [10,32]. 2.2.3. Interventional process At the scene, pre-hospital staffs took patient’s medical history, chief complain and clinical assessment. In case of emergency dyspnea was detected, patient was put on oxygen therapy via face mask or nasal cannula. After 5 minutes, all unresponsive cases (SpO2 < 95% with 5 liter/min) were applied CPAP-B for breathing support. Portable monitor was also attached for SpO2 and heart rate monitoring. CPAP level was initiated at 5 cm water, increasing every 2.5 cm water by adjusting oxygen flow in order to maintain SpO2 ≥ 95%. Maximum CPAP level was 10 cm water. Those patients with CPAP-B whose signs and symptoms got worse during intervention process such as more severe respiratory, unstable hemodynamic, SpO2 < 95% with CPAP of 10 cm water or having any risk of complication such as vomiting, pneumothorax, aspiration must be terminated the CPAP-B therapy for other emergency procedures such as: intubation, larynx mask airway, AMBU. On arrival at the Emergency room, CPAP-B 7 therapy could be ended for other intervention depend on the indication of physician in charge there. Two samples for arterial blood gas analysis were taken before and after using CPAP-B. 2.2.4. Research variables - General characteristics of target population: Age, gender, medical history, time of service, duration of intervention - Clinical characteristics of patients with emergency dyspnea: Level of consciousness, signs and symptoms of respiratory failure, vital signs. - Characteristics of arterial blood gas of patients with emergency dyspnea: pH, PaO2, PaCO2, HCO3- Interventional result and related undesired effects:  Success rate  Comparison clinical, vital signs changes before and after intervention  Comparison arterial blood gas before and after intervention  Proportion of undesired effects related to CPAP-B 2.2.5. Research criteria Level of consciousness: In pre-hospital setting, we applied AVPU scale to assess level of consciousness [25]. Diagnoses in pre-hospital setting: In this research, we used clinical practice guideline of Queensland ambulance service Queensland Australia [12,13,14,15] for diagnosis of respiratory failure and its causes. In the pre-hospital setting, those diagnoses mainly based on clinical signs and symptoms. Respiratory failure classification: criteria of Allal 2012 [8] 8 Success criteria (all following:)  SpO2 maintained above 95%  Heart rate reduction > 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. 9 CHAPTER 3 RESULT 3.1. General characteristic of target population  There were 150 patients enrolled in this study, mean of age was 73.5 ± 14.7 year old, youngest was 22, oldest was 97 year old. There were more male than female, gender proportion of male over female was 2.26:1 aproximately.  Time of service was similar between day time (6h-18h) and night time (18h-6h). Average duration of care from on-scene to hospotal was 29.5 ± 11 minutes, minimum was 10 minutes, maximum was 66 minutes. 68.7% patients was transported within 11 to 30 minutes  In this research, there were 5 causes of emergency dypsnea. They were pneumonia (53 patients, 35.3%), acute COPD exacerbation (44 patients, 29.3%), pulmonary edema (31 patients, 20.7%), asthma attack (18 patients, 12.0%), 4 patients (2.7%) with prior diagnosis of lung cancer. 3.2. Characteristics of clinical manifestation and ABG of emergency dyspnea patients 3.2.1. Characteristics of clinical manifestation Table 3.5. Level of consciousness Level of consciousness n Percentage Alert 121 80.7 % Response to Verbal 24 16.0 % Response to Pain 5 3.3 % Unresponsive 0 0.0 % 150 100 % Total Comment: 19.3 % patients altered mental status, no patient had U level on AVPU scale 10 Table 3.6. Cyanosis Cyanosis n Percentage Yes 150 100 % No 0 0% Comment: Before intervention, all patients had cyanosis sign at different level. Table 3.7. Difficulty in taking n Percentage Talks in sentence 1 0.7 % Talks in phases 63 42.0 % Talks in words 48 32.0 % Unable to talk 38 25.3 % Total 150 100 % Comment: Most of patients (99.3%) could not talks in sentence Table 3.8. Diaphoresis Diaphoresis n Percentage Yes 45 30 % No 105 70 % Total 150 100 % Comment: Only 30% patients had diaphoresis Table 3.9. Paradoxical abdominal movements Paradoxical abdominal movements n Percentage Yes 33 22 % No 117 78 % Total 150 100 % Comment: 1/5 patients had sign of paradoxical abdominal movements 11 Table 3.10. Accessory muscle breathing Accessory muscle breathing n Percentage Yes 144 96 % No 6 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 0.0 % 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 <7.35 45 30 % 7.35-7.45 57 38 % >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 <0,01 Chart 3.5. Mental status changes before and after intervention Comment: after intervention, mental status was improved significantly 13 Table 3.18. Cyanosis before and after intervention Phase sign n Percentage Total p Cyanosis 150 100 % Pre150 intervention Non-Cyanosis (100%) 0 0% < 0,01 Cyanosis 3 2% Post150 intervention Non-Cyanosis (100%) 147 98 % Comment: there was no cyanosis in most of patient after intervention, Table 3.19. Difficulty in taking before and after intervention Phase sign n Percentage Total p Talks in sentence 1 0.7 % PreTalks in phases 63 42.0% 150 intervention (100%) Talks in words 48 32.0% Unable to talk Talks in sentence 38 5 25.3% 3.3 % < 0.01 Talks in phases 123 82.0 % Post150 intervention Talks in words (100%) 7 4.7 % Unable to talk 15 10.0 % Comment: Taking ability’s improved significantly after intervention p <0,01 Chart 3.7. Paradoxical abdominal movements before and after intervention Comment: after intervention this sign was improved significantly 14 Table 3.20. Accessory muscle breathing before and after intervention Phase Accessory muscle breathing n Percentage Total Preintervention Yes 144 96.0% 150 No 6 4.0% (100%) Post- Yes 136 90.7 % 150 intervention No 14 9.3 % (100%) p > 0,05 Comment: Accessory muscle breathing before and after intervention had no difference p <0,01 Chart 3.8. Level of clinical respiratory failure before and after intervention Comment: Level of clinical respiratory failure was deducted significantly after intervention 15 Table 3.21. Vital signs before and after intervention ̅ ± SD) Variable Phase (𝐗 Min Max p Pre 71.6 ± 8.1 46 86 SpO2 < 0.01 (%) Post 98.1 ± 2.4 88 100 Pre 125.2 ± 12.0 90 156 Heat rare < 0.01 (beat/min) Post 107.6 ± 10.1 87 134 Pre 32.5 ± 5.3 20 56 Respiratory rate < 0.01 (beat/min) Post 23.2 ± 3.0 17 32 Comment: After intervention, SpO2 was increased, heart rate, respiratory rate were decreased significantly 3.3.2. Arterial blood gas changes before and after intervention Table 3.25. Arterial blood gas before and after intervention ̅ ± SD) Variable Phase (𝐗 Min Max p Pre 60.98 ± 10.14 38.0 79.7 PaO2 < 0.01 (mmHg) Post 110.70 ± 19.19 82.5 187.6 Pre 44.51 ± 13.55 20.1 82.2 PaCO2 < 0.01 (mmHg) Post 41.48 ± 9.76 19.6 69.9 Pre 24.65 ± 4.84 13.2 37.1 HCO30.439 (mmol/L) Post 24.62 ± 4.31 16.3 35.4 Pre 7.38 ± 0.89 7.15 7.58 pH < 0.01 Post 7.40 ± 0.74 7.24 7.56 Comment: after intervention, PaO2, PaCO2, pH improved significantly 3.4. Result of CPAP-B therapy and related undesired effects Table 3.35. Result of CPAP-B therapy in pre-hospital setting Result n Percentage Success 143 95.3 % Failure 7 4.7 % Total 150 100 % Comment: 95.3% patients with CPAP-B therapy got improvement. 16 Table 3.40. Undesired effects related to CPAP-B therapy Undesired effects n Percentage Skin redness around mask area 11 7.3 % Vomiting 2 1.3 % Abdominal distension 2 1.3 % Comment: There was no life-threatening complication during intervention. The most common undesired effect was redness of skin around mask area. CHAPTER 4 DISCUSSION 4.1. Characteristics of clinical manifestation and arterial blood gas of patients with emergency dyspnea 4.1.1. Clinical manifestation In this research, all patients with emergency dyspnea developed signs and symptoms of acute respiratory failure. 100% target group was cyanosis, 99.3% had difficulty in talking (42% talking in phrase, 32 % talking in word, 25.3% unable to talk). 30% patients were with diaphoresis, 22% were with sign of Paradoxical abdominal movements, 96% with sign of accessory muscle breathing. Vital sign prior intervention reflexed status of respiratory failure. Tachycardia with heart rate was 125.2 ± 12.0 beat/min, tachypnea with respiratory rate was 32.5 ± 5.3 breath/min; hypoxemia with SpO2 was 71.6 ± 8.1 %. Foreign and domestic relevant researches did not mention about classical signs and symptoms of respiratory failure. This can be understood that clinical manifestations were subjective and nonspecific therefore they were not paid attention in other researches. However, clinical signs and symptoms are still playing important roles 17 in the context of pre-hospital care in Viet Nam where modern monitors and equipment are not always available. 4.1.2. Arterial blood gas of target population Mean PaO2 was 60.98 ± 10.14 mm Hg, tantamount to moderate and severe respiratory failure, this matched with clinical level of respiratory failure. Patient’s level of pre-interventional PaO2 in this research was not as severe as those in research of Nguyễn Thị Thanh Thủy (55.9 ± 9.4 mmHg) [7] and Lê Đức Nhân ( 50.9 ± 9.5 mmHg) [3], but similar to result of Phùng Nam Lâm (61.6 ± 18.10 mmHg) [9]. Nguyễn Thị Thanh Thủy and Lê Đức Nhân focused to patients with acute pulmonary edema only, hence level of PaO2 in their study was much higher than research of Phùng Nam Lâm and ours since our target population were patients with respiratory failure from all causes, not only acute pulmonary edema. Pre-interventional PaCO2 (44.51 ± 13.55 mmHg) was higher than patients in researches of Nguyễn Thị Thanh Thủy (39.7 ± 11.4 mmHg) and Lê Đức Nhân (36.8 ± 12.6 mmHg). Doing deep analysis in each group of diagnosis, we revealed that patients with high level of PaCO2 prior intervention were those who suffered from acute COPD exacerbation (59.4 ± 9.97 mmHg), PaCO2 level of patients with acute pulmonary edema were 36.9 ± 8.3 mmHg, similar to result of two above studies. Mean HCO3- level was in physiological range (24.65 ± 4.84 mmHg). This might be because kidneys and buffer systems must take hours to days to balance acid-base. Therefore we assumed that level of HCO3- had not much change during acute phase of respiratory failure, especially in pre-hospital setting. There were 30% patient had acidosis, 32% had alkalosis. This abnormality was because of different causes of acute respiratory failure. 18 4.2. Effectiveness of CPAP-B in emergency dyspnea management 4.2.1. Clinical effectiveness of CPAP-B CPAP-B help improving clinical symptoms: 98% patients had no cyanosis after intervention, 59.9% improved talking ability, paradoxical abdominal movements was reduced to 12% in comparison with pre-intervention. Clinical level of respiratory failure was improved significantly (p<0.01). Before intervention, 93.3% patients were at level 2 and 3 of respiratory failure, after intervention there was only 4% had the same level, most of patients got deduction in respiratory failure to level 1. CPAP-B is a breathing support device, help improving ventilation and oxygenation so that secure patient’s life on rout of transport. However CPAP-B cannot treat causes of respiratory failure therefore respiratory status of patients in this research could only be improved, not resolved completely. 4.2.2. Vital signs changes before and after intervention 4.2.2.1. SpO2 CPAP-B helped improving level of SpO2 rapidly. 5 minutes after stating therapy, mean SpO2 went from 71.6 ± 8.1% up to 89.36 ± 3.29% and kept increasing in the next point of times. This change was significant with p value p < 0.001 and similar to research of Eva Eiske Spijker. Mean level of SpO2 after intervention in Eva Spijker’s research (98.23 ± 2.64%) was lower than ours [19]. The difference in target population might explain the gap between two researches. Eva Spijker’s population were only 16 patients with acute pulmonary edema, in our research, sample size was significantly larger including 150 patients with respiratory failure from all causes.
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