Effect of ED management on ICU use in acute pulmonary edema

• Published in: The American journal of emergency medicine 1999-10, Vol.17 (6), p.571-574
• Main Authors: Sacchetti, Alfred, Ramoska, Edward, Moakes, Mary Ellen, McDermott, Peg, Moyer, Vern
• Format: Article
• Language: English
• Subjects: Acute Disease; Acute pulmonary edema; Aged; Analgesics, Opioid - therapeutic use; Analysis of Variance; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Angiotensin-Converting Enzyme Inhibitors - therapeutic use; Biological and medical sciences; BiPAP; captopril; Captopril - therapeutic use; Diuretics - therapeutic use; Emergency and intensive respiratory care; Emergency Treatment; endotracheal intubation; Heart Failure - complications; Heart Failure - therapy; Humans; ICU utilization; Intensive care medicine; Intensive Care Units - statistics & numerical data; Logistic Models; Medical sciences; morphine; Morphine - therapeutic use; New Jersey; Nitroglycerin - therapeutic use; noninvasive pressure support ventilation; Odds Ratio; Pulmonary Edema - etiology; Pulmonary Edema - therapy; Respiratory Therapy; Retrospective Studies; Vasodilator Agents - therapeutic use
• ISSN: 0735-6757; 1532-8171
• DOI: 10.1016/S0735-6757(99)90198-5

Acute pulmonary edema (APE) is a common Emergency Department (ED) presentation requiring admission to an intensive care unit (ICU). This study was undertaken to examine the effect of ED management on the need for ICU admission in patients with APE. ED records of APE patients were abstracted for patient age, prehospital and ED pharmacological treatment, diagnoses, airway interventions, and ICU length of stay (LOS). Statistical analysis was through multiple regression, logistic regression, chi-square, and ANOVA. One hundred eighty-one patients composed the study group. Pharmacological treatment included nitroglycerin (NTG), 147 patients (81%); morphine sulfate (MS), 88 (49%); loop diuretics (LD), 133 (73%); and captopril sublingual (CSL), 47 (26%). Use of CSL and MS were associated with opposing needs for ICU admission. MS use was associated with increased ICU admissions (odds ratio, 3.08; P = .002), whereas CSL use was associated with decreased ICU admissions (odds ratio, 0.29; P = .002). Morphine sulfate use also demonstrated an increased need for endotracheal intubation (ETI) (odds ratio, 5.04; P = .001), whereas CSL demonstrated a decreased need for ETI (odds ratio, 0.16; P = .008). Ninety-three patients required some form of respiratory support. Forty received noninvasive pressure support ventilation (NPSV) from a bilevel positive airway pressure system (BiPAP), and 60 received endotracheal intubation. Some patients received more than 1 form of respiratory support; all other patients received supplemental oxygen only. The ICU-LOS associated with different airway interventions were supplemental oxygen, 0.72 days; BiPAP, 1.48 days; and ETI, 3.70 days ( P < .001). Specific ED pharmacological interventions are associated with a decreased need for ICU admission and endotracheal intubation in acute pulmonary edema patients, whereas use of noninvasive pressure support ventilation correlates with a reduction in the ICU length of stay for patients who do require critical care admission.