What are the pre-hospital treatment modalities for respiratory failure with impending cardiac arrest (periarrest)?

From the Guidelines

Prehospital treatment for respiratory failure in periarrest situations should prioritize oxygen therapy with a target saturation >94%, along with the use of sublingual or intravenous nitrates and intravenous diuretics, as recommended by the Acute Cardiovascular Care Association (ACCA) of the ESC 1. When managing patients with respiratory failure, it is crucial to consider the underlying pathology, such as cardiogenic shock or haemodynamic compromise, to guide treatment decisions.

• Key treatment modalities include:
  • Oxygen therapy to maintain a target saturation >94%
  • Sublingual or intravenous nitrates titrated according to blood pressure
  • Intravenous diuretics, such as furosemide, for patients with pulmonary edema
  • Non-invasive ventilation, including pre-hospital continuous positive airway pressure (CPAP), for patients with respiratory distress
  • Inotropic or vasopressor support for patients with haemodynamic compromise In cases where non-invasive ventilation is unsuccessful or contraindicated, invasive ventilation may be necessary 1.
• It is essential to continuously monitor the patient's vital signs, oxygen saturation, and end-tidal CO2, if available, to guide treatment decisions and adjust therapy as needed. The goal of prehospital treatment is to prevent cardiac arrest by addressing the underlying causes of respiratory failure, improving oxygenation, and reducing the work of breathing, as outlined in the position paper by the ACCA of the ESC 1.

From the FDA Drug Label

The manifestations of fentanyl overdosage are an extension of its pharmacologic actions with the most serious significant effect being hypoventilation. Treatment For the management of hypoventilation, immediate countermeasures include removing the fentanyl transdermal system and physically or verbally stimulating the patient These actions can be followed by administration of a specific narcotic antagonist such as naloxone. Always ensure a patent airway is established and maintained, administer oxygen and assist or control respiration as indicated and use an oropharyngeal airway or endotracheal tube if necessary.

Pre-hospital treatment modalities for respiratory failure due to fentanyl overdosage include:

• Removing the fentanyl transdermal system
• Physically or verbally stimulating the patient
• Administering a specific narcotic antagonist such as naloxone
• Ensuring a patent airway is established and maintained
• Administering oxygen and assisting or controlling respiration as indicated
• Using an oropharyngeal airway or endotracheal tube if necessary 2

From the Research

Pre-Hospital Treatment Modalities for Respiratory Failure

• The treatment of respiratory failure in the pre-hospital setting involves the administration of supplemental oxygen to maintain a SpO2 above 92% and below 98% 3.
• High-flow nasal cannula oxygen (HFNC) is recommended as a first-line noninvasive respiratory support in patients requiring more than 6 L/min of oxygen or PaO2/FiO2 ≤ 200 mm Hg and a respiratory rate above 25 breaths/minute or clinical signs of respiratory distress 3.
• Non-rebreathing masks (NRM) can provide oxygen concentration up to 95% and may be used in patients with respiratory failure, but prolonged use (>2 hours) may increase mortality in patients with pulmonary disease 4.
• Low-flow nasal oxygen supplementation in addition to a non-rebreathing mask may be an alternative to high-flow nasal cannula oxygenation in resource-limited settings 5.

Pathology and Treatment Considerations

• Acute hypoxemic respiratory failure is defined as PaO2 < 60 mm Hg or SpO2 < 90% on room air, or PaO2/FiO2 ≤ 300 mm Hg 3.
• The choice of oxygen therapy device depends on the patient's condition, with HFNC being superior to conventional oxygen therapy (COT) in avoiding intubation 3.
• Continuous positive airway pressure (CPAP) and noninvasive ventilation (NIV) may not be recommended as first-line treatments if HFNC is available 3.
• The use of NRM or low-flow nasal oxygen supplementation may be considered in patients with COPD in acute respiratory distress, but the effectiveness of these treatments needs to be assessed by randomized controlled trials 6, 5.