BiPaP in APE/CHF

[roja]

So, we are reading some review articles and two of them quote a study that had increased mortality (MI's) with biPap. However, this study had only 23 patients and two patients died..


So, it begs the question,

do you use bipap as NIV in APE/CHF?

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[Termwean]

I am a respiratory therapist and at my hospital we use Bipap or vapotherm first, sometimes it works when combined with diuretics/ tx's(even though tx's don't help chf REALLY!). If they come in, in an advanced state then you might as well just intubate them immediately.

So, we are reading some review articles and two of them quote a study that had increased mortality (MI's) with biPap. However, this study had only 23 patients and two patients died..


So, it begs the question,

do you use bipap as NIV in APE/CHF?

 

[southerndoc]

We use BiPAP very frequently. Sometimes it works, sometimes it doesn't. More often than not, patients usually get better with BiPAP and diuresis and rarely require intubation.

Roja, can you forward me those studies you are reviewing?

Cheers!

 

[Sessamoid]

Regardless, N=23 doesn't make for a very strong study.

 

[Termwean]

Eggsactly !

Regardless, N=23 doesn't make for a very strong study.

 

[roja]

I concur... and the general philosophy here is bipap in a patient that is needing NIV. The to review articles are the EMP reviews.. fairly respected review articles....so I was curious...


southerndoc, if you want the review articles, lPM me your email.. I will send them your way...

 

[southerndoc]

Regardless, N=23 doesn't make for a very strong study.

Sorry, I was under the impression that you had multiple articles. (???)

 

[Sessamoid]

I concur... and the general philosophy here is bipap in a patient that is needing NIV. The to review articles are the EMP reviews.. fairly respected review articles....so I was curious...


southerndoc, if you want the review articles, lPM me your email.. I will send them your way...

Can you post the citations? I'm interested in them as well.

 

[roja]

sure. I will dig them out tomm.. I am waiting for takout and today was crazy...


admission admission admission!

 

[southerndoc]

Speaking of which, anyone interested in a new subforum: EBM? It would be a great way to discuss various things... Have someone pick an article, give everyone a week to read it, and then discuss it. Much like our journal clubs, but this could be at everyone's pace and we could do an article or two every month.

Any takers?

 

[Sessamoid]

Speaking of which, anyone interested in a new subforum: EBM? It would be a great way to discuss various things... Have someone pick an article, give everyone a week to read it, and then discuss it. Much like our journal clubs, but this could be at everyone's pace and we could do an article or two every month.

Any takers?

Actually, I was considering starting a new website similar to that. Based on some content management system like slashcode (famous for Slashdot of course) or phpNuke. An online journal club of sorts.

 

[pinbor1]

This is something I would definitely be interested in and I know quite a few residents in my program as well as others that would be interested in this. I think it would be especially helpful to review the articles that are now be used for board certification/recertification. I hear it's ~10 articles a year. Does anyone have the list of those?

 

[docB]

Actually, I was considering starting a new website similar to that. Based on some content management system like slashcode (famous for Slashdot of course) or phpNuke. An online journal club of sorts.

Great idea. I'd go for it.

 

[southerndoc]

2004 Reading List

Selections from Immune System Disorders, Musculoskeletal Disorders (Non-traumatic), and Thoracic-Respiratory Disorders

Content Area 9. Immune System Disorders
Cines DB, Blanchette VS. Immune thrombocytopenic purpura. N Engl J Med. March 2002;346:995-1008.

Schriger DL, Mikulich VJ. The management of occupational exposures to blood and body fluids: revised guidelines and new methods of implementation. Ann Emerg Med. March 2002;39:319-328.

Content Area 11. Musculoskeletal Disorders (Non-traumatic)
Deyo RA, Weinstein JN. Low back pain. N Engl J Med. February 2001;344:363-370.

Perron AD, Miller MD, Brady WJ. Orthopedic pitfalls in the ED: pediatric growth plate injuries. Am J Emerg Med. January 2002;20:50-54.

Content Area 16. Thoracic-Respiratory Disorders
Gibbs MA, Camargo Jr CA, Rowe BH, et al. State of the art: therapeutic controversies in severe acute asthma. Acad Emerg Med. July 2000;7:800-815.

Small PM, Fujiwara PI. Management of tuberculosis in the United States. N Engl J Med. July 2001; 345:189-200.

Kline JA, Johns KL, Colucciello SA, et al. New diagnostic tests for pulmonary embolism. Ann Emerg Med. February 2000;35:168-180.

American College of Emergency Physicians. Clinical policy for the management and risk stratification of community-acquired pneumonia in adults in the Emergency Department. Ann Emerg Med. July 2001;38:107-113.

Orebaugh SL. Difficult airway management in the Emergency Department. J Emerg Med. January 2002;22:31-48.

Vichinsky EP, Neumayr LD, Earles AN, et al. Causes and outcomes of the acute chest syndrome in sickle cell disease. N Engl J Med. June 2000;342:1855-1865.

Selections from the Remainder of the Listing of Conditions and Components
The Model of the Clinical Practice of Emergency Medicine

Content Area 3. Cardiovascular Disorders
Weber JM, Chudnofsky CR, Boczar M, et al. Cocaine-associated chest pain: how common is myocardial infarction? Acad Emerg Med. August 2000;7:873-877.

Content Area 5. Endocrine, Metabolic & Nutritional Disorders
Harrigan RA, Nathan MS, Beattie P. Oral agents for the treatment of type 2 diabetes mellitus: pharmacology, toxicity, and treatment. Ann Emerg Med. July 2001;38:68-78.

Content Area 6. Environmental Disorders
Bouchama A, Knochel JP. Heat stroke. N Engl J Med. June 2002;346:1978-1988.

Hackett PH, Roach RC. High-altitude illness. N Engl J Med. July 2001;345:107-114.

Content Area 10. Systemic Infectious Disorders
Ryan ET, Wilson ME, Kain KC. Illness after international travel. N Engl J Med. August 2002;347:505-516.

Content Area 17. Toxicologic Disorders
Bond GR. The role of activated charcoal and gastric emptying in gastrointestinal decontamination: a state-of-the-art review. Ann Emerg Med. March 2002;39:273-286.

Mettler FA Jr, Voelz GL. Major radiation exposure - what to expect and how to respond. N Engl J Med. May 2002;346:1554-1561.

Content Area 18. Traumatic Disorders
Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med. July 2000;343:94-99.

Solomon DH, Simel DL, Bates DW, et al. Does this patient have a torn meniscus or ligament of the knee? JAMA. October 2001;286:1610-1620.

Content Area 20. Other Components
Schenkel S. Promoting patient safety and preventing medical error in emergency departments. Acad Emerg Med. November 2000;7:1204-1222.

2005 Reading List

Selections from Nervous System Disorders and Toxicologic Disorders

Content Area 12. Nervous System Disorders
deGans J, van de Beek D. Dexamethasone in adults with bacterial meningitis. N Eng J Med. Nov 2002;347:1549-1556.

Hasbun R, Abrahams J, Jekel J, et al. Computed tomography of the head before lumbar puncture in adults with suspected meningitis. N Engl J Med. Dec 2001;345:1727-1733.

Lewandowski C, Barsan W. Treatment of acute ischemic stroke. Ann Emerg Med. Feb 2001;37:202-216.

Schutzman SA, Greenes DS. Pediatric minor head trauma. Ann of Emerg Med. Jan 2001; 37:65-74.

Warden CR, Zibulewsky J, Mace S, et al. Evaluation and management of febrile seizures in the out-of-hospital and emergency department settings. Ann Emerg Med. Feb 2003;41:215-222.

Content Area 17. Toxicologic Disorders
Blackburn P, Vissers R. Pharmacology of emergency department pain management and conscious sedation. Emerg Med Clin N Am. Nov 2000;18:803-826. (Note: The content of this reading also relates to Content Area 19, Procedures and Skills.)

Brent J, McMartin K, Phillips S, et al. Fomepizole for the treatment of methanol poisoning. N Engl J Med. Feb 2001;344:424-429.

Kosten TR, O'Connor PG. Management of drug and alcohol withdrawal. N Engl J Med. May 2003;348:1786-1794.

Mason PE, Kerns WP II. Gamma hydroxybutyric acid (GHB) intoxication. Acad Emerg Med. July 2002;9:730-739.

Shannon M. Ingestion of toxic substances by children. N Engl J Med. Jan 2000;342:186-191.

Selections from the Remainder of the Listing of Conditions and Components
The Model of the Clinical Practice of Emergency Medicine

Content Area 1. Signs, Symptoms, and Presentations
Goldman B. Vertigo and dizziness. Tintinalli JE, et al (eds): Emergency Medicine, A Comprehensive Study Guide, ed 5, 2000, pp 1452-1463.

Kapoor WN. Syncope. N Engl J Med. Dec 2000;343:1856-1862.

Content Area 3. Cardiovascular Disorders
Andersen HR, Nielsen TT, Rasmussen K, et al. A comparison of coronary angioplasty with fibrinolytic therapy in acute myocardial infarction. N Engl J Med. August 2003;349:733-742.

Young JB, Publication Committee for the VMAC Investigators. Intravenous nesiritide vs nitroglycerin for treatment of decompensated congestive heart failure: a randomized controlled trial. JAMA. March 2002;287:1531-1540.

Zimetbaum PJ, Josephson ME. Use of the electrocardiogram in acute myocardial infarction. N Engl J Med. March 2003;348:933-940.

Content Area 10. Systemic Infectious Disorders
Petersen LR, Marfin AA, Gubler DJ. West Nile virus. JAMA. July 2003;290:524-528.

Content Area 16. Thoracic-Respiratory Disorders
McIntosh K. Community-acquired pneumonia in children. N Engl J Med. Feb 2002;346:429-436.

Content Area 18. Traumatic Disorders
Bulloch B, Neto G, Plint A, et al. Validation of the Ottawa knee rule in children: a multicenter study. Ann Emerg Med. July 2003;42:48-55.

Content Area 19. Procedures and Skills
Hollander JE, Singer AJ. Laceration management. Ann Emerg Med. Sept 1999;34:356-367.

Melanson SW, Heller MB. Principles of emergency department sonography. Tintinalli JE,et al (eds): Emergency Medicine, A Comprehensive Study Guide, ed 5, 2000, pp 1972-1982.

What say you people, where should we start? Should we have the Lee and the mods create a subforum for us? This would actually increase the amount of people who post to the EM forum if we draw fellow residents to this site.

 

[roja]

Emergency Medicine Practice. "Noninvasive Airway Management Techniques: How and When to Use them." July 2001 vol3, N7


The refrenced article (in this and in a review article on management of CHF) regarding BiPap and APE/CHF is #13

13. Wood, KA et al. The use of noninvasive positive pressure ventilation in the emergency department. Results of a randomized clinical trial. Chest 1998:113:1339-1346.


southerndoc I sent your the EMP review on NIV airway management. check your email.

 

[ERMudPhud]

I've always liked BIPAP for CHF since they often turn around so quick.

I'd be all for an EBM forum/online journal club. Will it be open to all comers? Invitation only? How do you keep the trolls out?

 

[ERMudPhud]

13. Wood, KA et al. The use of noninvasive positive pressure ventilation in the emergency department. Results of a randomized clinical trial. Chest 1998:113:1339-1346.

I took a quick look at the article and it is obviously limited by sample size which is why few of their p values reached significance. It can't really be used to adress the question of BIPAP in CHF since only 6/16 patients in the BIPAP arm and 4/11 in the control arm had CHF. I wonder if the increased death rate in the the BIPAP arm (4/16) vs the control arm (0/16) isn't due to the increased incidence of pneumonia in the BIPAP arm (7/16) vs (2/11). I wouldn't use BIPAP in pneumonia since those patients don't get better quickly and so if all four of their deaths were in the pneumonia group that might explain some things. Unfortunately although they stratify the ultimate cause of death they don't correlate with admission diagnosis. The interesting finding is that BIPAP delayed use of intubation by almost a day which might say that when we have a patient on bipap we might not be aggresive enough about moving to invasive ventillation. A larger study with three arms; BIPAP, Control, and BIPAP limited to only say 6 hours might show that BIPAP is fine but that its use should be for only a very finite period of time after which the decision to intubate or not has to be made.

 

[DrQuinn]

I'm all for it. In fact, I will ask Lee if we can open up a subforum in the EM forums... perhaps ERMudPhud, docB, or Sessamoid would like to moderate it? I'd have to ask Lee, but if that's something you're interested in, let me know.

I'd be all about it! I think it woudl also bring in a lot of traffic, too, especially from other residents or attendings.

Q