Guideline adhesion in the management of severe acute pulmonary oedema: a French survey involving 1048 cardiologists, emergency physicians, and intensivists.

Abstract

Background and importance: Acute pulmonary oedema is a frequent and potentially life-threatening emergency. Its management targets four key objectives: improving oxygenation, reducing volume overload, maintaining adequate blood pressure, and treating the underlying cause. Severe cases are mainly handled by cardiologists, emergency physicians, and intensivists, which may lead to variations in care and thus nonadherence to guidelines.

Objective: To evaluate interspecialty differences in the management of patients with severe acute pulmonary oedema and compare physicians' practices to 2021 European guidelines.

Design: A national cross-sectional survey using clinical vignettes.

Settings and participants: Four clinical vignettes, developed by a multidisciplinary scientific committee representing French cardiology, emergency medicine, and intensive care societies were distributed between June and September 2022 to physicians from the three specialties and to a panel of 20 experts.

Outcome measures and analysis: The primary outcome was adherence to European guidelines. Interspecialty differences and predictors of nonadherence were assessed using univariate and multivariate analyses.

Main results: A total of 1048 physicians responded (59% emergency physicians, 22% intensivists, and 19% cardiologists). Adherence rates were 66, 65, 69, and 76%, respectively among cardiologists, emergency physicians, intensivists, and experts. Intensivists and emergency physicians were more prone to initiate noninvasive ventilation than cardiologists (respectively 87, 82, and 71%, P  < 0.001 and P  < 0.01). Intensivists and cardiologists were more likely to intubate patients than emergency physicians (respectively 73, 65, and 43%, P  < 0.001 for both comparisons). Cardiologists more frequently administered intravenous diuretics (98%) compared with emergency physicians and intensivists (both 90%, P  = 0.002). Emergency physicians chose more frequently the correct door-to-balloon delay than cardiologists for ST-segment elevation myocardial infarction-related acute pulmonary oedema (43 versus 28%, P  = 0.003). Multivariate analysis showed lower adherence among physicians compared with experts. Adherence was also lower among physicians older than 40 years and those working in nonuniversity hospitals.

Conclusions: This nationwide survey highlights marked discrepancies between European guidelines and clinical practice in the management of acute pulmonary oedema, with substantial variation across specialties regarding initiation of oxygen therapy, invasive ventilation, nitrates, or delay for thrombolysis of an ST-segment elevation myocardial infarction.