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Mark as Complete - article has all required sections

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	\| pdfurl=http://www.bmj.com/content/bmj/341/bmj.c5462.full.pdf		\| pdfurl=http://www.bmj.com/content/bmj/341/bmj.c5462.full.pdf
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	==Clinical Question==		==Clinical Question==

EdMason: Created page with "{{JC info | title= Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: randomised controlled trial | abbreviation..."

2017-12-10T19:59:01Z

Created page with "{{JC info | title= Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: randomised controlled trial | abbreviation..."

New page

{{JC info
| title= Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: randomised controlled trial
| abbreviation=
| expansion=
| published= 2010
| author= Austin MA et. al.
| journal= BMJ
| year= 2010
| volume=341
| issue=
| pages= c5462
| pmid= 20959284
| fulltexturl=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2957540/
| pdfurl=http://www.bmj.com/content/bmj/341/bmj.c5462.full.pdf
}}
==Clinical Question==
In the prehospital setting, does titrating oxygen saturation of patients with presumed AECOPD to SpO2 88-92% compared to high flow oxygen for all decrease prehospital and in-hospital mortality?

==Conclusion==
Compared to high flow oxygen, titrating supplemental oxygen to a target SpO2 of 88-92% decreased mortality overall, and decreased hypercapnia and acidosis in patients treated according to protocol.

==Major Points==
*Patients presenting with dyspnea often receive supplemental oxygen empirically to correct hypoxemia and for symptomatic relief <ref name='ref1'>http://www.clinmed.rcpjournal.org/content/2/5/449</ref>. However, in patients with COPD hyperoxia has been shown to increase the risk of hypercapnia and acidosis, possibly through decreasing respiratory drive and worsening VQ-mismatch by disruption of hypoxic pulmonary vasoconstriction<ref> https://www.ncbi.nlm.nih.gov/pubmed/3565937</ref>. Furthermore, observational studies have shown an association between high flow oxygen administration and length of stay, ICU admission and mortality<ref>http://thorax.bmj.com/content/55/7/550</ref><ref name='ref1'/>.
*In this study, paramedics were randomized to administer either high flow oxygen or oxygen titrated to 88-92% SpO2 to patients with suspected AECOPD along with standard treatments such as nebulized bronchodilators.
==Study Design==
*Cluster randomized controlled single centre parallel group trial.
*N=405
**214 had confirmed COPD by PFTs in the past 5 years
*Enrolment: June 2006 to July 2007
*Setting: Ambulance service in Hobart, Tasmania, Australia
==Population==
===Patient Demographics===
*All patients (n=405)
**Male: 49%
**Mean Age: 69
*Confirmed diagnosis of COPD (n=214)
**Male: 48%
**Mean Age: 68
**FEV1 from most recent PFT: 42.6% predicted
**Avg Pack years: 45.5
===Inclusion Criteria===
*Age ≥ 35
*Paramedic diagnosis of AECOPD based upon one or more of:
**appropriateness of symptoms
**patient-reported history of COPD
**>10 pack-year smoking history

===Exclusion Criteria===

==Interventions==
*Paramedics were randomized to administer one of two treatments:
**Active arm: Oxygen via nasal prongs to target an SpO2 or 88-92% + bronchodilators administered via nebulizer face mask over NPs driven by compressed air.
**Control arm: High flow oxygen via non-rebreather at 8-10 L/min + bronchodilators administered via nebulizer with oxygen 6-8L/min
==Outcomes==

===Primary Outcome===
Prehospital and in-hospital mortality
*21/226 (9%) in high flow arm vs. 7/179 (4%) in the titrated oxygen arm. RR 0.42 (95% CI: 0.20 to 0.89) p=0.02

===Secondary Outcomes===
Incidence of both invasive and non-invasive ventilation
*19/213 (9%) in high flow arm vs. 13/166 (8%) in the titrated oxygen arm. RR 0.88 (95% CI: 0.45 to 1.72) p=0.7.
**NIV 9/226 vs 8/179

===Subgroup analysis===
Confirmed COPD. (Analysis of PFT within last 5 years + medical records by respirologist blinded to treatment allocation)
*Mortality
**11/117 (9%) in high flow arm vs. 2/97 (2%) in the titrated oxygen arm. RR 0.22 (95%CI: 0.05 to 0.91) p=0.04
*Mean blood gasses (note the low # of patients who had blood gasses taken)
**pH: 7.29 (n=19) in high flow arm vs. 7.35 (n=19) in the titrated oxygen arm. Mean difference 0.06. p=0.11
**paCO2 (mmHg) : 77.8 (n=20) in high flow arm vs. 54.7 (n=20). Mean difference −23.1. p=0.06.

==Criticisms & Further Discussion==
*Treatment protocol violation occurred in 56% of patients in the titrated oxygen arm based on ambulance records. All violations involved administration of high flow oxygen at some point pre-hospital.
*Very few patients had a blood gas taken within 30 minutes of arrival at hospital. Those who did may represent a subgroup of sicker patients.
*Though hospital staff were instructed to treat according to patient assignment, data regarding whether patients received high flow oxygen in-hospital is largely missing.
*COPD subgroup defined retrospectively. In addition, this group excluded any patients who lacked recent PFTs, likely excluding patients with ''bona fide'' AECOPD.
*All patients were admitted to hospital which may not represent the typical disposition of all patients brought to EDs by ambulance for suspected AECOPD.
*Relatively little use of non-invasive ventilation, though this has been shown to improve hypercapnia and other outcomes in AECOPD.
*Nebulized treatments administered differently in each group.
*Single centre study, no blinding post-treatment initiation.
==External Links==

==See Also==

==Funding==
*Australian College of Ambulance Professionals (ACAP)
*FlaemNuova (equipment)
==References==
<references/>

[[Category:EBQ]]

EBQ:Titrated Oxygen Therapy for COPD Exacerbation - Revision history

Danbot: Mark as Complete - article has all required sections

EdMason: Created page with "{{JC info | title= Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: randomised controlled trial | abbreviation..."