OPALS Study; COMPRESSIONS-ONLY CPR; BYSTANDERS; HYPERVENTILATION

ALS Benefit for Respiratory Distress
     Stiell IG, Spaite DW, Field B, et al. Advanced life support for out-of-hospital respiratory distress. New England Journal of Medicine 356(21):2,156-;64, May 24, 2007.

     Abstract: Respiratory distress is a common symptom of patients transported to hospitals by emergency medical services 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 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 8,138 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 albuterol 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% CI, 0.4-;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-;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.

     Comment: This is good evidence that the prompt and correct treatment of patients with respiratory distress results in better immediate (greater prehospital improvement, lower incidence of ED intubation) and long-term (reduced mortality, better overall cerebral function) outcome. These are important results that identify a group of patients prehospital ALS treatment is likely to help.

     Perhaps even more promising is that the majority of the reduction in mortality was seen in patients with congestive heart failure (CHF). Our treatments for CHF have greatly improved since this study was concluded in 2000. With a de-emphasis or elimination of morphine and furosemide (Lasix), higher doses of nitroglycerin and the addition of CPAP (and perhaps even captopril), one would expect that outcomes today would be even better.

     As we learn more from excellent studies such as these, it helps us focus our quality improvement efforts. Previous OPALS papers have concluded that ALS care improves outcomes in patients with chest pain, but not cardiac arrest (where CPR and defibrillation are most important) or trauma. EMS systems should keep the treatment of chest pain and respiratory distress patients as high priorities in their QI systems.

CPR With Chest Compressions Only
     SOS-KANTO study group. Cardiopulmonary resuscitation by bystanders with chest compression only: An observational study. Lancet 369(9,565):920-;6, Mar 17, 2007.