Prehospital noninvasive pressure support ventilation for acute cardiogenic pulmonary edema.

Severe acute cardiogenic pulmonary edema (ACPE) can successfully be treated with noninvasive pressure support ventilation (NIPSV) in a clinical setting. Whether prehospital NIPSV starting early at patients' home and being continued until hospital arrival is feasible and improves ACPE emergency care is examined in this study. End points of the study were oxygen saturation at hospital admission and clinical outcome. Twenty-three patients suffering from severe cardiac pulmonary edema with severe dyspnea, an oxygen saturation of less than 90% and basal rales were included in this controlled prospective randomized trial. All patients received standard medical treatment and 10 patients were additionally treated with NIPSV (pressure support level, 12 cmH2O; positive endexpiratory pressure, 5 cmH2O; FiO2, 0.6) whereas the other patients received oxygen (8 l/min) via Venturi face mask. Improvement in oxygen saturation was significantly faster in the NIPSV group and oxygen saturation was higher at the time of the hospital admission (NIPSV=97.3+/-0.8%; standard=89.5+/-2.7%, P=0.002). A trend toward higher troponin T levels was seen in the standard treatment group. The need for intensive care treatment did not differ, and one patient of each treatment group died in hospital. No complications were noted during the treatment with NIPSV. Prehospital NIPSV is feasible and able to improve emergency management of ACPE.     

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.     

Pressure support noninvasive positive pressure ventilation treatment of acute cardiogenic pulmonary edema

We assessed cardiogenic pulmonary edema (CPE) patient response to full mask pressure support noninvasive positive pressure ventilation (NPPV). Adult patients presenting to the emergency department (ED) in acute respiratory failure who clinically required endotracheal intubation (ETI) were studied. In addition to routine therapy consisting of oxygen, nitrates, and diuretics, patients were started on full mask NPPV using a Puritan Bennett 7200 ventilator delivering pressure support 10 cm H(2)O, PEEP 5 cm H(2)O, FiO(2) 100%. Pressure support was titrated to achieve tidal volumes of 5 to 7 mL/kg, and PEEP titrated to achieve oxygen saturation (SaO(2)) > 90%. Outcome measures included arterial blood gas (ABG), Borg dyspnea score, vital signs, and need for ETI. Twenty patients mean age 74.7 +/- 14.3 years were entered on the study. Initial mean values on FiO(2) 100% by nonrebreather mask: pH 7.17 +/-.13, paCO(2) 65.5 +/- 19.4 mmHg, paO(2) 73.8 +/- 27.3 mm Hg, SaO(2) 89.7 +/- 10.0%, Borg score 8.1 +/- 1.4, and respiratory rate(RR) 38 +/- 6.3. At 60 minutes of NPPV, improvement was statistically significant: pH 7.28 (difference.11; 95% CI.04-.19), paCO(2) 45 (difference 20.5; 95% CI 8-33), Borg score 4.1 (difference 4.0; 95% CI 3-5), and RR 28.2 (difference 9.8; 95% CI 5-14). NPPV duration ranged from 30 minutes to 36 hours (median 2 hours, 45 minutes). Eighteen patients (90%) improved allowing cessation of NPPV. Two patients with concomitant severe chronic obstructive pulmonary disease (COPD) required ETI. There were no complications of NPPV. NPPV using full face mask and pressure support provided by a conventional volume ventilator is an effective treatment for CPE and may help prevent ETI.     

无创机械通气在治疗急性心源性肺水肿中的应用研究

目的探讨无创机械通气（NMV）治疗急性心源性肺水肿（ACPE）的临床应用价值。方法对80例各种原因所致的急性肺水肿患者随机分为NMV治疗组39例和对照组41例,对照组常规药物治疗加鼻导管高流量吸氧,NMV治疗组在常规药物治疗的基础上给予压力支持通气（PSV）加呼吸末正压（PEEP）通气模式,分别监测治疗前及治疗后的临床表现、动脉血气分析、血氧饱和度、呼吸频率、心率、血压等变化。结果治疗组治疗后,39例患者均于30min内症状缓解,除3例较重患者需辅助通气2h才能撤机外,其他均于1h内撤机。撤机后能平卧呼吸,面色恢复正常、大汗消失、口唇无青紫、泡沫样痰消失、双肺啰音明显减少甚至消失。两组临床各项指标比较差异均具有统计学意义（P〈0．05）。结论在常规强心、利尿、扩管等基础治疗同时,加用无创双水平正压机械通气治疗急性肺水肿,可迅速纠正缺氧、改善病情、提高抢救成功率,减少气管插管及气管切开率,降低死亡率。     

Non-invasive positive pressure ventilation for exacerbation of chronic obstructive pulmonary patients in the emergency department.

Patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) commonly present to the emergency department for treatment. Some of them, despite appropriate therapy become more dyspnoeic with increasing acute respiratory failure. The requirement for intubation and mechanical ventilation is for these patients often associated with a prolonged and complicated intensive care unit stay and has been associated with morbidity and mortality rates in excess. Non-invasive ventilation (NIV) emerged recently as a means of reducing those complications. NIV can be a safe and effective means of augmenting ventilation and decreasing inspiratory work in many patients with acute exacerbation of COPD. NIV is generally started in the intensive care unit. Except for a few negative studies, the overall compending studies seem to be in favour of the utilization of NIV in cases of exacerbation of COPD patients. There are few published data on the question whether NIV could or should be started earlier and initiated in the emergency department. It seems that NIV treatment could be an effective addition to standard treatment especially for acute exacerbation of COPD. A more extensive and routine use of non-invasive ventilation in the emergency department requires further study.     

急性心源性肺水肿机械通气治疗效果及对血流动力学的影响

目的研究急性心源性肺水肿(ACPE)机械通气治疗方法,比较持续气道正压成比例压力支持(CPAPPPS)、持续气道正压压力支持通气(CPAPPSV)两种模式对血流动力学的影响。方法77例ACPE患者进行无创、有创机械通气治疗,对其中机械通气时间超过24h的61例患者在有创机械通气开始与低辅助通气时用部分CO2重复呼吸法(无创心排血量,NICO)监测血流动力学变化,在药物干预下,对照研究两种模式下血流动力学变化。结果61例ACPE患者中33例行无创机械通气,成功24例(72.7%),33例有创机械通气(5例为无创转为有创机械通气),11例失败。控制通气应用双水平气道正压/压力支持通气(BIPAP/PSV),高水平压力(Phigh)16～24cmH2O(1cmH2O=0.098kPa),高水平压力时间(Thigh)1.5s,呼气末正压(PEEP)6～15cmH2O,吸入氧浓度(FiO2)0.5;有创机械通气撤机成功患者心排血量(CO)和心排血指数(CI)较有创机械通气撤机失败患者明显改善,低辅助通气采用PPS模式患者的CO和CI较采用PSV模式患者改善更明显(P均<0.001),有创机械通气撤机失败患者在药物干预下仍CI<1.5L·min-1·m-2。结论对ACPE患者应在血流动力学监测下进行药物干预及无创/有创机械通气治疗,宜采用压力控制模式,个体化调节PEEP,一般6～15cmH2O,依据临床情况尽快过渡到自主通气模式,对撤机困难者可应用CPAPPPS模式。     

Noninvasive mechanical ventilation in acute cardiogenic pulmonary edema

Acute cardiogenic pulmonary edema is a frequent life-threatening emergency. During the last 10 years, increasing attention has focused on the use of noninvasive ventilation to treat patients with various forms of acute respiratory failure. Numerous physiologic data and clinical studies support the use of noninvasive ventilation during cardiogenic pulmonary edema. Noninvasive ventilation results in rapid improvement of clinical signs of respiratory distress and gas exchange and decreases the need for endotracheal intubation for patients in the ICU with acute hypercapnic respiratory failure related to cardiogenic pulmonary edema. However, no sustained benefit (, decreased late mortality) or benefit for less severe forms of cardiogenic pulmonary edema has been demonstrated yet. Moreover, there are still few data that support the use of a specific mode of ventilation over the others.     

Noninvasive pressure support ventilation in non-COPD patients with acute cardiogenic pulmonary edema and severe community-acquired pneumonia: acute effects and outcome

OBJECTIVE: To compare the acute effects of noninvasive pressure support ventilation (NIPSV) in non-COPD patients with acute cardiogenic pulmonary edema (CPE) and severe community-acquired pneumonia (CAP) presenting with a similar hypoxemic respiratory failure and exploring the ensuing impact on outcome. DESIGN. Prospective, observational study. SETTING. Multidisciplinary ICU, regional teaching hospital. PATIENTS: Non-COPD patients with CPE or severe CAP. MEASUREMENTS AND RESULTS: Fifteen patients with CPE and eighteen with CAP were included. Both groups had similar low PaO2/FiO2 ratios at admission; SAPS II, baseline pH(a) were lower in the CPE group than in the CAP group. Within the first NIPSV observation period (60 min), the oxygenation improved significantly in both CPE and CAP-groups; respiratory rate (RR) significantly decreased in the CPE group ( P=0.005), but it remained unchanged in the whole CAP group; heart rate and mean arterial pressure significantly decreased in both groups. One patient (6.6%) in the CPE group and seven patients (38%) in the CAP group were intubated ( P=0.04). The mean total time spent on NIPSV was 9.6+/-6.3 h in the CPE and 37.2+/-36 h in the CAP group ( P=0.01). Unit mortality rate was 6.6% in the CPE and 28% in the CAP group ( P=0.2). Upon inclusion, all but one CAP patients who were subsequently intubated had a bacteremic pneumonia; unit mortality rate was 57% in intubated- and 9% in non-intubated CAP patients ( P=0.05). CONCLUSIONS: NIPSV equally and rapidly improved oxygenation in non-COPD patients with CPE and severe CAP presenting with a similar hypoxemic respiratory failure, but the subsequent outcome was definitely different in the two groups, depending on the nature of the acute lung injury.     

无创性正压通气治疗急性心源性肺水肿的临床探讨

目的 :探讨无创性正压通气治疗急性心源性肺水肿的疗效。方法 :3 0例常规治疗效果不佳的急性心源性肺水肿患者予无创性正压通气 ,观察治疗前后症状体征和动脉血气变化。结果 :无创性正压通气能迅速改善急性心源性肺水肿患者的症状、体征和动脉血气 ,在治疗开始后的 1/2h内PCO2 有显著性差异 (P <0 0 5 ) ,HR、RR、pH、SBP和PO2 有非常显著性差异 (P <0 0 1)。结论 :对符合指征的急性心源性肺水肿患者可首先使用无创性正压通气治疗     

无创正压通气应用于急性心源性肺水肿病人的护理

无创正压通气（NPPV）是指通过鼻罩、口鼻面罩或全面罩等无创性方式将病人与呼吸机相连进行正压辅助通气,它与气管插管和气管切开等有创的连接方式存在显著区别。有研究证明,NPPV可作为慢性阻塞性肺疾病（COPD）急性加重期和急性心源性肺水肿（ACPE）病人的一线治疗手段。     

无创正压通气治疗急性心源性肺水肿36例

目的 评价无创正压通气治疗急性心源性肺水肿的疗效。方法 选择36例急性心源性肺水肿患者,在高流量吸氧及常规药物治疗不能纠正缺氧时,经面罩给予无创正压通气,观察治疗前、治疗后0．5h、1h、2h后临床症状、体征和动脉血气分析的变化。结果 经面罩无创正压通气治疗后,36例患者中32例（88．89％）临床症状、体征明显改善,血气分析中PaO2明显升高（P〈0．01）、PaCO2有所下降（P〈0．05）,避免了进一步有创机械通气治疗带来的损伤和经济负担;4例（11．11％）经无创正压通气治疗无效,改为经口气管插管机械通气;死亡2例。结论 应用无创正压通气可明显改善急性心源性肺水肿患者的症状、体征和血气分析结果,可作为急性心源性肺水肿安全、快速、有效的治疗手段之一。     

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.     

Noninvasive pressure support ventilation (NIPSV) with face mask in patients with acute cardiogenic pulmonary edema (ACPE)

Objectives: To assess (1) the short-term hemodynamic, respiratory and arterial blood gas effects of NIPSV in patients with ACPE who were likely to require endotracheal intubation, (2) the initial causes of failure and (3) the side effects and the difficulties of this technique. Design: Uncontrolled, prospective clinical study. Setting: Teaching hospital intensive care unit. Patients: 26 consecutive patients with severe ACPE. Interventions: Noninvasive ventilation via a face mask, using a pressure support mode (20.5 ± 4.7 cmH₂O), with an initial fractional inspired oxygen of 93.0 ± 16 % and a positive end-expiratory pressure of 3.5 ± 2.3 cmH₂O. The need to intubate the patients within 48 h was considered as a criterion of failure of the procedure. Measurements and results: Clinical and biological parameters were measured at 15 and 30 minutes, 1 h and 2 h and at 1 h and 2 h, respectively. There were 5 (21 %) failures and 21 (79 %) successes. In both the success and the failure groups, clinical and blood gas parameters improved at the first measure. In the success group, within 15 min of the start of NIPSV, pulse oximetry saturation (SpO₂) had increased from 84 ± 12 to 96 ± 4 % (p < 0.001), the respiratory rate (RR) had decreased from 36 ± 5.3 to 22.4 ± 4.9 breaths/min (p < 0.0001) and within 1 h the arterial oxygen tension and pH, respectively, had increased from 61 ± 14 to 270 ± 126 mmHg (p < 0.0001) and from 7.25 ± 0.11 to 7.34 ± 0.07 (p < 0.01) and the arterial carbon dioxide tension (PaCO₂) had decreased from 54.2 ± 15 to 43.4 ± 6.4 mmHg (p < 0.01). There were no statistical differences between the success and failure groups for the initial clinical parameters: SpO₂, RR, heart rate, mean arterial pressure. The only differences between the success and failure groups were in the PaCO₂ (54.2 ± 15 vs 32 ± 2.1 mmHg, p < 0.001) and the creatine kinase (CPK) (176 ± 149 vs 1282 ± 2080 IU/l, p < 0.05); this difference in CPK activity was related to the number of patients who had an acute myocardial infarction (AMI) (4/5 in the failure group vs 2/21 in the success group, p < 0.05). All patients with AMI in the failure group died. Conclusion: Among patients in acute respiratory failure, those with severe ACPE could benefit from NIPSV if they are hypercapnic, but NIPSV should be avoided in those with AMI. Received: 22 January 1998 Final revision received: 3 September 1998 Accepted: 24 September 1998     

Boussignac continuous positive airway pressure device in the emergency care of acute cardiogenic pulmonary oedema: a randomized pilot study.

This study aimed to assess the short-term respiratory effects of a new portable device that delivers a continuous positive airway pressure via a face mask (Boussignac-CPAP) in patients with severe acute cardiogenic pulmonary oedema, and the feasibility of using this technique in an emergency department. We prospectively studied 30 consecutive patients with acute cardiogenic pulmonary oedema. They were randomly assigned either to the Boussignac-CPAP valve, which delivered oxygen, or to standard oxygen delivery for a duration of 30 min. The end-expiratory pressure reached 9.3+/-0.3 cm H2O with the Boussignac-CPAP valve. At the end of the 30 min period, the decreases in respiratory rate and muscular activity were significantly greater among patients assigned to the Boussignac-CPAP valve compared with those on standard oxygen delivery [24+/-1.6 breaths/min, median 24 (15-37) versus 28.5+/-1.9, median 27 (16-38) and 1.3+/-0.2, median 1 (0-4) versus 2.7+/-0.3, median 2 (0-4), respectively]. Moreover, the arterial oxygen tension to inspired oxygen concentration ratio and tidal volume were improved at the end of the 30 min Boussignac-CPAP period compared with baseline. Boussignac-CPAP was easily implemented and no side-effects were reported. Continuous positive pressure delivered using the Boussignac-CPAP device is feasible in an emergency care setting. It can quickly improve respiratory distress in acute cardiogenic pulmonary oedema patients. A larger trial should be initiated in such an emergency care setting to demonstrate the effectiveness of the Boussignac-CPAP device.     

Non-invasive pressure support ventilation in severe community-acquired pneumonia

OBJECTIVE: To explore three aspects of non-invasive pressure support ventilation (NIPSV) applied by face mask to patients with acute respiratory failure (ARF) due to severe community-acquired pneumonia (CAP): (1) the initial acute effects on respiratory rate, gas exchange and hemodynamics, (2) the clinical course and outcome during ICU and hospital stay, (3) the nursing workload as measured by the daily PRN 87 (Project Research in Nursing) score. SETTING: Medical ICU, University Hospital. DESIGN: Prospective, observational study. PATIENTS: Patients without any prior history of chronic lung disease, consecutively admitted to the ICU to receive NIPSV for ARF due to severe CAP. MEASUREMENTS AND RESULTS: (means +/- SD): Twenty-four patients aged 49+/-17 years, admission APACHE II 13+/-5, were included. Admission PaO2/FIO2, alveolar-arterial oxygen difference (DA-aO2) and PaCO2 were 104+/-48, 447+/-120 and 40+/-10 mmHg, respectively. All patients were normotensive. During the initial NIPSV trial respiratory rate decreased from 34+/-8 to 28+/-10 breaths/min (p < 0.001) and arterial oxygenation improved (PaO2/FIO2 104+/-48 vs 153+/-49, DA-aO2 447+/-120 vs 370+/-180 mmHg, p < 0.001) while PaCO2 remained unchanged. There were no hemodynamic effects. Subsequently, a total of 133 NIPSV trials were performed (median duration 55 min, range 30-540 min) over 1-7 days. No complication occurred during NIPSV. Sixteen patients were intubated (66%) 1.3+/-1 days after inclusion. Upon inclusion, the patients who were subsequently intubated were older (55+/-15 vs 37+/-12 years) and more severely hypoxemic (63+/-11 vs 80+/-15 mmHg, p < 0.05) than those not requiring intubation. Eight patients died (33 %), all in the intubated group. Median lengths of stay in the ICU and hospital were longer in intubated patients (ICU 16 days, range 3-64 vs 6 days, range 3-7, p < 0.05; hospital 23 days, range 9-77 vs 9.5 days, range 4-42, p < 0.05). Mean daily total PRN points were stable throughout the NIPSV period and were not different between the groups. Only 14% of PRN points resulted from respiratory therapy interventions. PRN score was higher during the first 24 h following intubation than during the first 24 h of NIPSV (278+/-55 vs 228+/-24 points, p < 0.05). CONCLUSION: Despite initial improvement in arterial oxygenation with NIPSV in patients with ARF due to severe CAP, the intubation rate is high. However, the more favorable outcome and shorter ICU and hospital stays when intubation is avoided, as well as the short delay required to assess the success or failure of NIPSV warrants a trial of NIPSV in this setting. The nursing workload remains stable during NIPSV and does not result predominantly from respiratory therapy interventions.     

无创正压通气治疗急性心源性肺水肿的临床疗效观察

目的：观察无创正压通气（ NPPV）治疗急性心源性肺水肿的临床疗效。方法对48例急性心源性肺水肿引起的急性呼吸衰竭患者行NPPV,观察治疗期间心率和经皮血氧饱和度的变化,比较治疗前及治疗后2 h血气情况。结果急性心源性肺水肿患者治疗后2h缺氧症状得到明显改善,心悸、呼吸困难及紫绀明显好转,心功能评级明显降低（P﹤0.01）。结论对急性心源性肺水肿引起的急性呼吸衰竭行NPPV疗效显著,具有良好的临床实用价值,值得推广。     

关于急性心源性肺水肿的机械通气策略

机械通气是抢救各种原因所导致急性呼吸衰竭 ( ARF)的有效手段。从病理生理学角度认识呼吸衰竭(呼衰 )的病因为通气障碍、非心源性肺水肿及心源性肺水肿 ,典型代表疾病为慢性阻塞性肺疾病 ( COPD)、急性呼吸窘迫综合征 ( ARDS)和急性心源性肺水肿 ( ACPE)。近年来国内外研究的重点是 COPD、ARDS的发病机制与机械通气治疗方法 ;对 ACPE的研究主要是基础研究及药物治疗。 2 0世纪 70年代 Swan Ganz导管的问世使人们对 ACPE病理生理变化的异常有了更清楚的认识 ,促进了 ACPE的药物治疗进展。然而导管的放置非但不能改善预后 ,还…