Advanced Life Support for Out-of-Hospital Respiratory Distress

[Guest guest]

I'm SHOCKED! You mean........you mean........you mean.......YOUUU MEANNNN,

paramedics really do have an impact on patient care?

Must be a mistake. Oh, it's a Canadian study. Can't be any good.

Doesn't apply to the U.S. Had me goin there for a minute.

Gene Gandy, JD, LP

>

> Published in this week's New England Journal of Medicine (NEJM) and part of

> the published OPALS research.

>

> ABSTRACT

>

> Background Respiratory distress is a common symptom of patients transported

> to hospitals by emergency medical services (EMS) personnel. The benefit of

> advanced life support for such patients has not been established.

>

> Methods The Ontario Prehospital Advanced Life Support (OPALS) Study was a

> controlled clinical trial that was conducted in 15 cities before and after

> the implementation of a program to provide advanced life support for

> patients with out-of-hospital respiratory distress. Paramedics were trained

> in standard advanced life support, including endotracheal intubation and the

> administration of intravenous drugs.

>

> Results The clinical characteristics of the 8138 patients in the two phases

> of the study were similar. During the first phase, no patients were treated

> by paramedics trained in advanced life support; during the second phase,

> 56.6% of patients received this treatment. Endotracheal intubation was

> performed in 1.4% of the patients, and intravenous drugs were administered

> to 15.0% during the second phase. This phase of the study was also marked by

> a substantial increase in the use of nebulized salbutamol and sublingual

> nitroglycerin for the relief of symptoms. The rate of death among all

> patients decreased significantly, from 14.3% to 12.4% (absolute difference,

> 1.9%; 95% confidence interval [CI], 0.4 to 3.4; P=0.01) from the

> basic-life-support phase to the advanced-life- basic-life-support phase to

> ratio, 1.3; 95% CI, 1.1 to 1.5).

>

> Conclusions The addition of a specific regimen of out-of-hospital

> advanced-life- advanced-life-<wbr>support interventions to an existing EMS

> basic life support was associated with a decrease in the rate of death of

> 1.9 percentage points among patients with respiratory distress.

>

> Article attached or if the list does not accept attachments, by emailing me

> directly.

>

> Jim<

>

>

[Guest guest]

Published in this week's New England Journal of Medicine (NEJM) and part of

the published OPALS research.

ABSTRACT

Background Respiratory distress is a common symptom of patients transported

to hospitals by emergency medical services (EMS) personnel. The benefit of

advanced life support for such patients has not been established.

Methods The Ontario Prehospital Advanced Life Support (OPALS) Study was a

controlled clinical trial that was conducted in 15 cities before and after

the implementation of a program to provide advanced life support for

patients with out-of-hospital respiratory distress. Paramedics were trained

in standard advanced life support, including endotracheal intubation and the

administration of intravenous drugs.

Results The clinical characteristics of the 8138 patients in the two phases

of the study were similar. During the first phase, no patients were treated

by paramedics trained in advanced life support; during the second phase,

56.6% of patients received this treatment. Endotracheal intubation was

performed in 1.4% of the patients, and intravenous drugs were administered

to 15.0% during the second phase. This phase of the study was also marked by

a substantial increase in the use of nebulized salbutamol and sublingual

nitroglycerin for the relief of symptoms. The rate of death among all

patients decreased significantly, from 14.3% to 12.4% (absolute difference,

1.9%; 95% confidence interval [CI], 0.4 to 3.4; P=0.01) from the

basic-life-support phase to the advanced-life-support phase (adjusted odds

ratio, 1.3; 95% CI, 1.1 to 1.5).

Conclusions The addition of a specific regimen of out-of-hospital

advanced-life-support interventions to an existing EMS system that provides

basic life support was associated with a decrease in the rate of death of

1.9 percentage points among patients with respiratory distress.

Article attached or if the list does not accept attachments, by emailing me

directly.

Jim<

[Guest guest]

>>> I'm SHOCKED! You mean........you mean........you

mean.......YOUUU MEANNNN, paramedics really do have an impact on

patient care? <<<

It would be hard to draw that conclusion from this study. This trial

was part of the OPALs study. Previous phases of OPALs trials have

shown that advanced-life-support programs have no significant effect

on the outcomes of patients with cardiac arrest.

The objective of this prospective " before-and-after " controlled trial

was to examine the effects that ALS had on the prehospital management

of respiratory distress. The study was conducted in 18 cities

throughout Ontario, most of which had populations over 100,000. Only

cities that met certain EMS performance criteria were selected.

It is unclear whether these " advanced care paramedics " are similar in

scope to American Paramedics. The study paper suggests that in order

to get them to the advanced level, primary care paramedics had to be

trained in endotracheal intubation, how to insert IV lines, and how

to administer IV medications. This suggests that a " paramedic " in

Canada is probably closer to an EMT-Basic in America. The

Canadian " Advanced Care Paramedics " described in the paper are

probably closer to EMT-Intermediates in the States.

The only medications mentioned in the paper that could be used for

the respiratory distress patients were intravenous furosemide and

morphine as well as nebulized salbutamol and sublingual nitroglycerin.

Although there was a significant reduction in overall mortality

during the advanced-life-support phase of the trial (14.3% vs 12.4%;

absolute difference, 1.9%; 95% confidence interval [CI], 0.4 to 3.4;

P=0.01), the magnitude of the observed decrease did not exceed the

prespecified, minimal, clinically important difference of 2

percentage points. This difference in mortality was entirely

accounted for by a decrease in the in-hospital mortality, whereas the

mortality in the emergency department was unchanged.

The most substantial change in therapeutic intervention during the

trial was a tremendous increase in the use nebulized salbutamol and

sublingual nitroglycerin (15.7% to 59.4%). In Canada, these

medications may be administered by basic life support providers.

Thus, the benefit of the intervention in this trial may have been

primarily due to the increased use of " basic " therapy instead

of " advanced-life-support. "

Limitations

1. Before-and-after controlled trial rather than as a randomized

trial (historical rather than a contemporaneous control group

2. Nebulized salbutamol and sublingual nitroglycerin were introduced

during the " before " phase of the study (may have been a factor that

influenced the benefit in the " after " phase)

3. Positive-airway-pressure therapy was also introduced in some

emergency departments during the study period; this could have

influenced the outcome for some of the patients in the study.

Kenny Navarro

UT Southwestern Medical Center at Dallas

[Guest guest]

OK - I've been involved in just as much research as anyone else with an advanced

degree. We DO need research. We cant have enough. I interpret this different

from Kenny, as an overall positive outcome. However, when we are taking ONE

profession doing ONE skill set and determining overall patient outcome, are we

not condemning that profession to death? Most likely....

________________________________

From: texasems-l [texasems-l ] On Behalf Of Kenny

Navarro [kenneth.navarro@...]

Sent: Thursday, May 24, 2007 2:23 PM

To: texasems-l

Subject: Re: Advanced Life Support for Out-of-Hospital Respiratory

Distress

>>> I'm SHOCKED! You mean........you mean........you

mean.......YOUUU MEANNNN, paramedics really do have an impact on

patient care? <<<

It would be hard to draw that conclusion from this study. This trial

was part of the OPALs study. Previous phases of OPALs trials have

shown that advanced-life-support programs have no significant effect

on the outcomes of patients with cardiac arrest.

The objective of this prospective " before-and-after " controlled trial

was to examine the effects that ALS had on the prehospital management

of respiratory distress. The study was conducted in 18 cities

throughout Ontario, most of which had populations over 100,000. Only

cities that met certain EMS performance criteria were selected.

It is unclear whether these " advanced care paramedics " are similar in

scope to American Paramedics. The study paper suggests that in order

to get them to the advanced level, primary care paramedics had to be

trained in endotracheal intubation, how to insert IV lines, and how

to administer IV medications. This suggests that a " paramedic " in

Canada is probably closer to an EMT-Basic in America. The

Canadian " Advanced Care Paramedics " described in the paper are

probably closer to EMT-Intermediates in the States.

The only medications mentioned in the paper that could be used for

the respiratory distress patients were intravenous furosemide and

morphine as well as nebulized salbutamol and sublingual nitroglycerin.

Although there was a significant reduction in overall mortality

during the advanced-life-support phase of the trial (14.3% vs 12.4%;

absolute difference, 1.9%; 95% confidence interval [CI], 0.4 to 3.4;

P=0.01), the magnitude of the observed decrease did not exceed the

prespecified, minimal, clinically important difference of 2

percentage points. This difference in mortality was entirely

accounted for by a decrease in the in-hospital mortality, whereas the

mortality in the emergency department was unchanged.

The most substantial change in therapeutic intervention during the

trial was a tremendous increase in the use nebulized salbutamol and

sublingual nitroglycerin (15.7% to 59.4%). In Canada, these

medications may be administered by basic life support providers.

Thus, the benefit of the intervention in this trial may have been

primarily due to the increased use of " basic " therapy instead

of " advanced-life-support. "

Limitations

1. Before-and-after controlled trial rather than as a randomized

trial (historical rather than a contemporaneous control group

2. Nebulized salbutamol and sublingual nitroglycerin were introduced

during the " before " phase of the study (may have been a factor that

influenced the benefit in the " after " phase)

3. Positive-airway-pressure therapy was also introduced in some

emergency departments during the study period; this could have

influenced the outcome for some of the patients in the study.

Kenny Navarro

UT Southwestern Medical Center at Dallas