Tuesday, December 22, 2015

Acute respiratory failure after drowning: a retrospective multicenter survey


TitleAcute respiratory failure after drowning: a retrospective multicenter survey
Authors: Michelet P, et al.
Journal: European Journal of Emergency Medicine, December 2015

This article evaluates the pre-hospital and ICU care of non-fatal drowning patients experiencing acute respiratory failure (ARF).  Treatment modalities included supplemental oxygen, non-invasive ventilations (NIV) [BiPap, CPAP], and intubation with mechanical ventilation (MV).  The authors' aim was to analyze the course of these patients and to describe the efficacy of NIV when used.

Study design: Retrospective review of EMS and ICU over 3 summers, 7 ICUs
Inclusion: all adult patients with ARF after drowning in regional Mediterranean Sea

The Numbers: 88 patients

  • 37 started on supplemental oxygen
    • 23 switched to NIV in ICU (due to worsening mentation or respiratory status)
    • None intubated
    • All discharge without neurologic sequelae
  • 25 started on NIV
    • 4 switched to MV in ICU (3 for respiratory failure, 1 for neuro decline)
    • Average initial GCS 12 +/- 3
    • All discharged without neurologic sequelae
  • 26 intubated on scene
    • Average GCS 7 +/- 2
    • 3 vegetative state, 2 moderate disabilities
Conclusions
  • NIV was useful in this population.  More than 80% of NIV remained stable and avoided intubation
  • Initial poor GCS and respiratory status associated with need for MV and worse outcome
Review

There are 3 things I really like about this article: (1) they stick to the Utstein style of reporting and utilize the Szpilman Classification for drowning, (2) they show the utility of high-quality, combined pre-hospital/ICU data collection, and (3) they provide the largest data set to date evaluating the use of NIV in drowning patients.  Before this study, there were only a few cases studies to guide our use of NIV in these patients.  These authors give us evidence on which to base our practice; evidence that tell us that even if the patient has a depressed mental status, if they are protecting their airway to the point that you don't need to immediately intubate, NIV may be tried and is associated with successful treatment and discharge from ICU without neurologic sequelae. 

Reference:

Michelet P, Bouzana F, Charmensat O, Tiger F, Durand-Gasselin J, Hraiech S,Jaber S, Dellamonica J, Ichai C. Acute respiratory failure after drowning: aretrospective multicenter survey. Eur J Emerg Med. 2015 Dec 17.