• Cost-effectiveness of out-of-hospital continuous positive airway pressure for acute respiratory failure: decision analytic modelling using data from a feasibility trial

      Thokala, Praveen; Fuller, Gordon W.; Goodacre, Steve; Keating, Samuel; Herbert, Esther; Perkins, Gavin; Rosser, Andy; Gunson, Imogen; Miller, Joshua; Ward, Matthew; et al. (2021-01-25)
    • The Diagnostic accuracy of prehospital assessment of acute respiratory failure

      Fuller, Gordon W.; Goodacre, Steve; Keating, Samuel; Herbert, Esther; Perkins, Gavin D.; Ward, Matthew; Rosser, Andy; Gunson, Imogen; Miller, Joshua; Bradburn, Mike; et al. (2020-12-01)
      Acute respiratory failure (ARF) is a common medical emergency. Pre-hospital management includes controlled oxygen therapy, supplemented by specific management options directed at the underlying disease. The aim of the current study was to characterise the accuracy of paramedic diagnostic assessment in acute respiratory failure. Methods: A nested diagnostic accuracy and agreement study comparing pre-hospital clinical impression to the final hospital discharge diagnosis was conducted as part of the ACUTE (Ambulance CPAP: Use, Treatment effect and Economics) trial. Adults with suspected ARF were recruited from the UK West Midlands Ambulance Service. The pre-hospital clinical impression of the recruiting ambulance service clinician was prospectively recorded and compared to the final hospital diagnosis at 30 days. Agreement between pre-hospital and hospital diagnostic assessments was evaluated using raw agreement and Gwets AC1 coefficient. Results: 77 participants were included. Chronic obstructive pulmonary disease (32.9%) and lower respiratory tract infection (32.9%) were the most frequently suspected primary pre-hospital diagnoses for ARF, with secondary contributory conditions recorded in 36 patients (46.8%). There was moderate agreement between the primary pre-hospital and hospital diagnoses, with raw agreement of 58.5% and a Gwets AC1 coefficient of 0.56 (95% CI 0.43 to 0.69). In five cases, a non-respiratory final diagnosis was present, including: myocardial infarction, ruptured abdominal aortic aneurysm, liver failure and sepsis. Conclusions: Pre-hospital assessment of ARF is challenging, with limited accuracy compared to the final hospital diagnosis. A syndromic approach, providing general supportive care, rather than a specifically disease-orientated treatment strategy, is likely to be most appropriate for the pre-hospital environment. Abstract published with permission.
    • Incidence of acute respiratory failure cases in West Midlands Ambulance Service (WMAS) – sub-study of ACUTE (ambulance CPAP: use, treatment effect and economics) trial

      Gunson, Imogen M.; Herbert, Esther; Fuller, Gordon W. (2019-09-24)
      Background Acute respiratory failure (ARF) is a life-threatening emergency and pre-hospital CPAP may improve outcomes. A CPAP cost-effectiveness determinant is the incidence of eligible patients with ARF. This sub-study of the ACUTE trial aimed to determine the number of adults with ARF potentially suitable for CPAP, presenting to WMAS. Methods This observational study was conducted between 1stAugust 2017 and 31st July 2018. Adult patients presenting with SpO2 <94% were identified from WMAS electronic patient records. Electronic filters applied ACUTE trial inclusion and exclusion criteria, with subsequent manual clinical review by a research paramedic. A second research paramedic checked a sub-sample for inter-rater agreement. Overall and monthly incidence rates were calculated, census data provided the population denominator. Results 108,391 potential patients were identified from electronic patient records (EPR), after filter application 4,526 cases were eligible for review (Figure 1). After review, 1017 cases were considered CPAP candidates. Inter-rater agreement was 86%. Overall incidence was 17.35 per 100,000 population per year (95%CI 16.3–18.5). Marked seasonal variation was present, increasing over winter (Figure 2). Urban areas had the highest proportion of eligible patients (67.6% v 18.3% Rural v 14.2% semi-rural); and 53.0% of all eligible were male. Conclusions The incidence of eligible ARF patients impacts on the cost-effectiveness of pre-hospital CPAP, but previous reports have been variable, using sub-optimal methods or from non-UK settings. We report a valid NHS estimate of 17 patients per 100,000 who do not respond to current pre-hospital ARF management and could be candidates for CPAP., https://emj.bmj.com/content/36/10/e11.3. This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ DOI http://dx.doi.org/10.1136/emermed-2019-999abs.26
    • Prehospital continuous positive airway pressure for acute respiratory failure: the ACUTE feasibility RCT

      Fuller, Gordon W.; Keating, Samuel; Goodacre, Steve; Herbert, Esther; Perkins, Gavin; Rosser, Andy; Gunson, Imogen; Miller, Joshua; Ward, Matthew; Bradburn, Mike; et al. (2021-02)