Continuous positive airway pressure for cardiogenic pulmonary edema: a randomized study

Study Objective

The purpose of this randomized controlled trial was to determine the immediate and delayed effects of noninvasive ventilation for patients in acute cardiogenic pulmonary edema (ACPE) in addition to aggressive usual care in a medical prehospital setting.

Methods

Out-of-hospital patients in severe ACPE were eligible for the study. Patients were randomized to receive either usual care, including conventional optimal treatment with furosemide, oxygen, and high-dose boluses of isosorbide dinitrate plus oxygen, or conventional medications plus out-of-hospital continuous positive airway pressure (CPAP). The primary outcome was the treatment success defined as all of respiratory rate less than 25 breaths per minute and oxygen saturation of greater than 90% at the end of 1-hour study. Secondary end points included death during 30 days after inclusion. Lengths of intensive care unit and hospital stays were also recorded.

Results

In total, 124 patients were enrolled into the study. The 2 groups had similar baseline characteristics. For the primary outcome analysis, 22 (35.5%) of 62 patients were considered as experiencing a treatment success in the usual care group vs 19 (31.7%) of 60 in the CPAP group (P = .65). Seven patients died within 30 days in the usual care group vs 6 in the CPAP group (P = .52). There were no statistically significant differences between the treatment groups for length of stay either in hospital or in the intensive care unit.

Conclusion

In the prehospital setting, in spite of its potential advantages for patients in ACPE, CPAP may not be preferred to a strict optimal intravenous treatment.     

Bi-level positive airway pressure (BiPAP) and acute cardiogenic pulmonary oedema (ACPO) in the emergency department.

Patients in acute respiratory failure (ARF) frequently present to the emergency department (ED). Traditionally management has involved mechanical ventilation via endotracheal intubation. Such invasive forms of treatment, however, correlate with a higher incidence of infection, mortality, length of stay and contribute to the costs of intensive care. Non-invasive positive pressure ventilation (NIPPV) such as bi-level positive airway pressure (BiPAP) may therefore provide an alternative and preferable form of treatment. Whilst contemporary literature supports the use of BiPAP in hypercapnic ARF, its role in acute hypoxaemic presentations remains elusive. Specifically, the efficacy and safety of BiPAP in the treatment of acute cardiogenic pulmonary oedema (ACPO) remains a contentious issue. The aim of this paper is to explore the physiological rationale for treatment of ACPO with BiPAP. Particular attention will focus on the comparative theoretical advantages of BiPAP in relation to continuous positive airway pressure (CPAP), and a review of recent research. Discussion will incorporate timeliness in the application of BiPAP, indicators of successful treatment, appropriate manipulation of pressure settings, nursing workload and management of patients beyond the ED. Whilst the theoretical advantages of BiPAP ventilation are acknowledged, larger randomised controlled research studies are recommended in order to clearly ensure its safe and effective application in the treatment of ACPO.     

A comparison of continuous and bi-level positive airway pressure non-invasive ventilation in patients with acute cardiogenic pulmonary oedema: a meta-analysis

Introduction  

We conducted the present study to investigate the potential beneficial and adverse effects of continuous positive airway pressure (CPAP) compared with bi-level positive airway pressure (BiPAP) noninvasive ventilation in patients with cardiogenic pulmonary oedema.     

Mortality in acute cardiogenic pulmonary edema treated with continuous positive airway pressure

Objective  To investigate mortality in acute cardiogenic pulmonary edema (ACPE) patients treated with continuous positive airway pressure (CPAP) and to identify clinical and laboratory characteristics associated with mortality. Design  Observational, retrospective study. Setting  Emergency Medicine Department. Patients and participants  A total of 454 consecutive ACPE patients treated with CPAP. Measurements and results  Demographics, past medical history, clinical characteristics, laboratory evaluation, in-hospital mortality data were collected. Potential predictors of in-hospital mortality that were considered of clinical relevance and immediately accessible on admission were investigated by multivariable logistic regression. ACPE-related mortality rate was 3.8% (17/452 patients) and the in-hospital mortality rate was 11.4% (50/440 patients). Significant independent predictors of increased risk of in-hospital mortality were: advanced age (P = 0.012), normal-to-low blood pressure (P < 0.001), low PaO₂/FiO₂ ratio (P = 0.020), hypocapnia (P = 0.009) and anemia (P = 0.05). Conclusions  Values recorded within few minutes from arrival to the hospital can predict mortality in ACPE patients treated with CPAP who has been tested, for the first time, in a real life study. This can allow physicians to quickly recognize more severe ACPE patients treated with CPAP and plan for aggressive monitoring and treatment and for deciding the better site of care.     

双水平正压通气在急性心源性肺水肿中的应用

目的:探讨双水平正压通气治疗急性心源性肺水肿的疗效。方法:收集内科2003年1月至2007年8月收治的92例急性心源性肺水肿患者的临床资料并进行分析。治疗组46例在应用常规抗心源性肺水肿药物的同时联用BiPAPS/T30或BiPAP-Synchrony呼吸机进行无创通气治疗,对照组46例只应用常规药物治疗。结果:治疗组患者临床症状、体征明显改善,心率、呼吸频率、血压与治疗前比较显著降低,SaO2与治疗前比较显著增高(P<0.05),总有效率93.5%。对照组总有效率仅为82.6%。结论:双水平正压通气治疗急性心源性肺水肿疗效确切。     

Noninvasive continuous positive airway pressure in elderly cardiogenic pulmonary edema patients

Objective To compare the physiological effects and the clinical efficacy of continuous positive airway pressure (CPAP) vs standard medical treatment in elderly patients (75 years) with acute hypoxemic respiratory failure related to cardiogenic pulmonary edema.Design A prospective, randomized, concealed, and unblinded study of 89 consecutive patients who were admitted to the emergency departments of one general, and three teaching, hospitals.Intervention Patients were randomly assigned to receive standard medical treatment alone (n=46) or standard medical treatment plus CPAP (n=43).Measurements Improvement in PaO₂/FIO₂ ratio, complications, length of hospital stay, early 48-h and overall mortality, compared between the CPAP and standard treatment groups.Results Study groups were comparable with regard to baseline physiological and clinical characteristics (age, sex ratio, autonomy, medical history, cause of pulmonary edema). Within 1 h, noninvasive continuous positive airway pressure led to decreased respiratory rate (respiratory rate, 27±7 vs 35±6 breaths/min; p=0.009), and improved oxygenation (PaO₂/F_IO₂, 306±104 vs 157±71; p=0.004) compared with baseline, whereas no differences were observed within the standard treatment group. Severe complications occurred in 17 patients in the standard treatment group, vs 4 patients in the noninvasive continuous positive airway pressure group (p=0.002). Early 48-h mortality was 7% in the noninvasive continuous positive airway pressure group, compared with 24% in the standard treatment group (p=0.017); however, no sustained benefits were observed during the overall hospital stay.Conclusion Noninvasive continuous positive airway pressure promotes early clinical improvement in elderly patients attending emergency departments for a severe pulmonary edema, but only reduces early 48-h mortality.     

A comparison of bilevel and continuous positive airway pressure noninvasive ventilation in acute cardiogenic pulmonary edema

Background

Whether bilevel positive airway pressure (BiPAP) is advantageous compared with continuous positive airway pressure (CPAP) in acute cardiogenic pulmonary edema (ACPO) remains uncertain. The aim of the meta-analysis was to assess potential beneficial and adverse effects of CPAP compared with BiPAP in patients with ACPO.

Methods

Randomized controlled trials comparing the treatment effects of BiPAP with CPAP were identified from electronic databases and reference lists from January 1966 to December 2012. Two reviewers independently assessed study quality. In trials that fulfilled inclusion criteria, we critically evaluate the evidence for the use of noninvasive ventilation on rates of hospital mortality, endotracheal intubation, myocardial infarction, and the length of hospital stay. Data were combined using Review Manager 4.3 (The Cochrane Collaboration, Oxford, UK). Both pooled effects and 95% confidence intervals (CIs) were calculated.

Results

Twelve randomized controlled trials with a total of 1433 patients with ACPO were included. The hospital mortality (relative risk [RR], 0.86; 95% CI, 0.65-1.14; P = .46; I² = 0%) and need for requiring invasive ventilation (RR, 0.89; 95% CI, 0.57-1.38; P = .64; I² = 0%) were not significantly different between patients treated with CPAP and those treated with BiPAP. The occurrence of new cases of myocardial infarction (RR, 0.95; 95% CI, 0.77-1.17; P = .53, I² = 0%) and length of hospital stay (RR, 1.01; 95% CI, − 0.40 to 2.41; P = .98; I² = 0%) were also not significantly different between the 2 groups.

Conclusions

There are no significant differences in clinical outcomes when comparing CPAP vs BiPAP. Based on the limited data available, our results suggest that there are no significant differences in clinical outcomes when comparing CPAP with BiPAP.     

Pharmacological therapy of acute cardiogenic pulmonary oedema in the emergency department

This paper critically reviews the major drug types that are currently used in the management of acute cardiogenic pulmonary oedema. As decompensated heart failure becomes an increasingly common problem in emergency departments in the developed world, optimization of emergency drug therapy for these critically ill patients is essential. The evidence base for 'routine therapy' in the ED is considered. The review also briefly considers emerging pharmacological therapies that may have an impact on future management of cardiogenic pulmonary oedema.     

Randomized, prospective trial of oxygen, continuous positive airway pressure, and bilevel positive airway pressure by face mask in acute cardiogenic pulmonary edema

OBJECTIVE: To compare the effects of oxygen, continuous positive airway pressure (CPAP), and bilevel positive airway pressure (bilevel-PAP) on the rate of endotracheal intubation in patients with acute cardiogenic pulmonary edema. DESIGN: Randomized, controlled trial. SETTING: Tertiary hospital emergency room. PATIENTS: We randomly assigned 80 patients with severe cardiogenic acute pulmonary edema into three treatment groups. Patients were followed for 60 days after the randomization. INTERVENTIONS: Oxygen applied by face mask, CPAP, and bilevel-PAP. MEASUREMENTS AND MAIN RESULTS: The rate of endotracheal intubation as well as vital signs and blood gases was recorded during the first 24 hrs. Mortality was evaluated at 15 days, at 60 days, and at hospital discharge. Complications related to respiratory support were evaluated before hospital discharge. Treatment with CPAP or bilevel-PAP resulted in significant improvement in the PaO2/FiO2 ratio, subjective dyspnea score, and respiratory and heart rates compared with oxygen therapy. Endotracheal intubation was necessary in 11 of 26 patients (42%) in the oxygen group but only in two of 27 patients (7%) in each noninvasive ventilation group (p = .001). There was no increase in the incidence of acute myocardial infarction in the CPAP or bilevel-PAP groups. Mortality at 15 days was higher in the oxygen than in the CPAP or bilevel-PAP groups (p < .05). Mortality up to hospital discharge was not significantly different among groups (p = .061). CONCLUSIONS: Compared with oxygen therapy, CPAP and bilevel-PAP resulted in similar vital signs and arterial blood gases and a lower rate of endotracheal intubation. No cardiac ischemic complications were associated with either of the noninvasive ventilation strategies.     

Continuous and bilevel positive airway pressure in the treatment of acute cardiogenic pulmonary edema

Patients with acute cardiogenic pulmonary edema (ACPE) are commonly seen in the emergency department (ED). Although the majority of patients respond to conventional medical therapy, some patients require at least temporary ventilatory support. Traditionally, this has been accomplished via endotracheal intubation and mechanical ventilation, an approach that is associated with a small but significant rate of complications. The past 2 decades have witnessed increasing interest in methods of noninvasive ventilatory support (NVS), notably continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP). We review the physiological consequences, clinical efficacy, and practical limitations of CPAP and BiPAP in the management of ACPE.     

Randomised controlled comparison of continuous positive airways pressure, bilevel non-invasive ventilation, and standard treatment in emergency department patients with acute cardiogenic pulmonary oedema

Background: Continuous positive airways pressure (CPAP) and bilevel non-invasive ventilation may have beneficial effects in the treatment of patients with acute cardiogenic pulmonary oedema. The efficacy of both treatments was assessed in the UK emergency department setting, in a randomised comparison with standard oxygen therapy.

Methods: Sixty patients presenting with acidotic (pH<7.35) acute, cardiogenic pulmonary oedema, were randomly assigned conventional oxygen therapy, CPAP (10 cm H₂O), or bilevel ventilation (IPAP 15 cm H₂O, EPAP 5 cm H₂O) provided by a standard ventilator through a face mask. The main end points were treatment success at two hours and in-hospital mortality. Analyses were by intention to treat.

Results: Treatment success (defined as all of respiratory rate<23 bpm, oxygen saturation of>90%, and arterial blood pH>7.35 (that is, reversal of acidosis), at the end of the two hour study period) occurred in three (15%) patients in the control group, seven (35%) in the CPAP group, and nine (45%) in the bilevel group (p = 0.116). Fourteen (70%) of the control group patients survived to hospital discharge, compared with 20 (100%) in the CPAP group and 15 (75%) in the bilevel group (p = 0.029; Fisher's test).

Conclusions: In this study, patients presenting with acute cardiogenic pulmonary oedema and acidosis, were more likely to survive to hospital discharge if treated with CPAP, rather than with bilevel ventilation or with conventional oxygen therapy. There was no relation between in hospital survival and early physiological changes. Survival rates were similar to other studies despite a low rate of endotracheal intubation.

     

Simple lightweight disposable continuous positive airways pressure mask to effectively treat acute pulmonary oedema: randomized controlled trial

Objective: To compare the novel Boussignac valve continuous positive airways pressure (CPAP) delivery mask and a standard closed‐circuit Drager CF800 CPAP system in the management of acute pulmonary oedema (APO) patients. Methods: This was a randomized controlled trial whereby patients presenting to the ED with APO and who met the study criteria received either CPAP via the Boussignac valve system or from a standard Drager CF800. Baseline physiological and arterial gas data were recorded and repeated at 30 and 60 min after CPAP commenced. The primary outcome was mean change in pCO₂ at 60 min between the two systems. Results: There were 39 evaluable patients (19 Boussignac, 20 Drager). The mean change in pCO₂ at 60 min compared to baseline was similar in the two groups (Boussignac 0.9 kPa vs. Drager 1.2 kPa, mean difference ?0.3; 95% CI ?1.0–0.5, P = 0.45). In addition, there were no significant differences at 60 min in regards to respiratory rate decrease, Boussignac 17.3/min versus Drager 19.6/min (mean difference 1.3; 95% CI ?3.3–5.8, P = 0.58) or peripheral SaO₂ increase, Boussignac 10.7% versus Drager 14.6% (mean difference ?3.9; 95% CI ?9.9–2.1, P = 0.19). There was no significant difference in disposition from the ED or the complication rate. Conclusions: The Boussignac valve system may be an effective lightweight disposable method of delivering CPAP to patients with APO. It appears to perform as effectively as much larger, more expensive and less transportable equipment.     

Acidemia does not affect outcomes of patients with acute cardiogenic pulmonary edema treated with continuous positive airway pressure

Introduction  

A lack of data exists in the literature evaluating acidemia on admission as a favorable or negative prognostic factor in patients with acute cardiogenic pulmonary edema (ACPE) treated with non-invasive continuous positive airway pressure (CPAP). The objective of the present study was to investigate the impact of acidemia on admission on outcomes of ACPE patients treated with CPAP.     

A case of unilateral re-expansion pulmonary oedema successfully treated with non-invasive continuous positive airway pressure.

Unilateral re-expansion pulmonary oedema is a rare threatening complication of the treatment of lung atelectasis, pleural effusion or pneumothorax, the pathogenesis of which is not completely known. The clinical picture varies considerably from asymptomatic radiological findings to dramatic respiratory failure with circulatory shock. There are few literature reports of the treatment of re-expansion pulmonary oedema with non-invasive continuous positive airway pressure. We present the case of a 75-year-old man who presented in our emergency room with a large left-sided spontaneous pneumothorax and developed severe respiratory failure and circulatory collapse after drainage via a chest tube. The diagnosis of unilateral re-expansion pulmonary oedema was made and he was successfully treated with non-invasive continuous positive airway pressure. Literature data about the aetiological and pathogenetic factors of the condition are also considered.     

Noninvasive pressure support ventilation vs. continuous positive airway pressure in acute hypercapnic pulmonary edema

Objective This study compared noninvasive pressure support ventilation (NIPSV) and continuous positive airway pressure (CPAP) in patients with acute hypercapnic pulmonary edema with regard to resolution time.Design and setting Randomized prospective study in an emergency department.Patients and participants We randomly assigned 36 patients with respiratory failure due to acute pulmonary edema and arterial hypercapnia (PaCO₂ >45 mmHg) to NIPSV (n=18) or CPAP through a face mask (n=18).Measurements and results Electrocardiographic and physiological measurements were made over 36 h. There was no difference in resolution time defined as clinical improvement with a respiratory rate of fewer than 30 breaths/min and SpO₂ of 96% or more between CPAP and NIPSV groups. Arterial carbon dioxide tension was significantly decreased after 1 h of ventilation (CPAP, 60.5±13.6 to 42.8±4.9 mmHg; NIPSV, 65.7±13.6 to 44.0±5.5 mmHg); respective improvements were seen in pH (CPAP, 7.22±0.11 to 7.37±0.04; NIPSV, 7.19±0.11 to 7.38±0.04), SpO₂ (CPAP, 86.9±3.7% to 95.1±2.6%; NIPSV, 83.7±6.6% to 96.0±2.9%), and respiratory rate (CPAP, 37.9±4.5 to 21.3±5.1 breaths/min; NIPSV, 39.8±4.4 to 21.2±4.6 breaths/min). No significant differences were seen with regards to endotracheal intubation and in-hospital mortality.Conclusions NIPSV proved as effective as CPAP in the treatment of patients with acute pulmonary edema and hypercapnia but did not improve resolution time.     

Helium-oxygen breathing in the early emergency care of acute severe asthma: a randomized pilot study.

The aim of this study was to establish whether a clinical trial, comparing helium-oxygen (HeO2) breathing to standard therapy, would be feasible during the out-of-hospital care of adult patients with severe asthma. Although the primary outcome in a definitive trial will be a decrease in morbidity, the present study primarily examined: (1) if the strategy could be successfully implemented in emergency ambulatory units; (2) if the research staff could enroll enough patients, given the resources. Nine patients were included in the conventional treatment group, and seven patients in the HeO2 group. Patients randomized to the HeO2 group breathed the mixture for a 12-hour period. Clinical and biological parameters improved for all patients. There was no trend towards a HeO2 benefit, whether during the initial out-of-hospital nor the ICU care. No patient was intubated within the study period. HeO2 breathing was considered to be simple to initiate, and no side effects were reported. In conclusion, while HeO2 breathing is easy to apply, even in the out-of-hospital setting, the few enrolled patients did not appear to benefit from this treatment. Regarding our low inclusion rate and the lack of positive effect trend, we believe that a large definitive trial will be difficult to initiate in such an emergency care setting.     

Continuous positive airway pressure vs. proportional assist ventilation for noninvasive ventilation in acute cardiogenic pulmonary edema

Objective To compare continuous positive airway pressure (CPAP) and proportional assist ventilation (PAV) as modes of noninvasive ventilatory support in patients with severe cardiogenic pulmonary edema. Design and setting A prospective multicenter randomized study in the medical ICUs of three teaching hospitals. Patients Thirty-six adult patients with cardiogenic pulmonary edema (CPA) with unresolving dyspnea, respiratory rate above 30/min and/or SpO₂ above 90% with O₂ higher than 10 l/min despite conventional therapy with furosemide and nitrates. Interventions Patients were randomized to undergo either CPAP (with PEEP 10 cmH₂O) or PAV (with PEEP 5–6 cmH₂O) noninvasive ventilation through a full face mask and the same ventilator. Measurements and results The main outcome measure was the failure rate as defined by the onset of predefined intubation criteria, severe arrythmias or patient's refusal. On inclusion CPAP (n = 19) and PAV (n = 17) groups were similar with regard to age, sex ratio, type of heart disease, SAPS II, physiological parameters (mean arterial pressure, heart rate, blood gases), amount of infused nitrates and furosemide. Failure was observed in 7 (37%) CPAP and 7 (41%) PAV patients. Among these, 4 (21%) CPAP and 5 (29%) PAV patients required endotracheal intubation. Changes in physiological parameters were similar in the two groups. Myocardial infarction and ICU mortality rates were strictly similar in the two groups. Conclusions In the present study PAV was not superior to CPAP for noninvasive ventilation in severe cardiogenic pulmonary edema with regard to either efficacy and tolerance. T. Rusterholtz and P.-E. Bollaert contributed equally to this study. This work was supported in part by Respironics Inc., Murrysville, PA, USA.     

Non-invasive pressure support ventilation and CPAP in cardiogenic pulmonary edema: a multicenter randomized study in the emergency department

Introduction

Noninvasive pressure support ventilation (NIPSV) and continuous positive airway pressure (CPAP) are both advocated in the treatment of cardiogenic pulmonary edema (CPE); however, the superiority of one technique over the other has not been clearly demonstrated. With regard to its physiological effects, we hypothesized that NIPSV would be better than CPAP in terms of clinical benefit.

Methods

In a prospective, randomized, controlled study performed in four emergency departments, 200 patients were assigned to CPAP (n?=?101) or NIPSV (n?=?99). Primary outcome was combined events of hospital death and tracheal intubation. Secondary outcomes included resolution time, myocardial infarction rate, and length of hospital stay. Separate analysis was performed in patients with hypercapnia and those with high B-type natriuretic peptide (>500?pg/ml).

Results

Hospital death occurred in 5 (5.0%) patients receiving NIPSV and 3 (2.9%) patients receiving CPAP (p?=?0.56). The need for intubation was observed in 6 (6%) patients in the NIPSV group and 4 (3.9%) patients in the CPAP group (p?=?0.46). Combined events were similar in both groups. NIPSV was associated to a shorter resolution time compared to CPAP (159?±?54 vs. 210?±?73?min; p?Conclusions During CPE, NIPSV accelerates the improvement of respiratory failure compared to CPAP but does not affect primary clinical outcome either in overall population or in subgroups of patients with hypercapnia or those with high B-type natriuretic peptide.