Noninvasive continuous positive airway pressure in elderly cardiogenic pulmonary edema patients Use of bilevel positive airway pressure in out-of-hospital patients. Randomized, prospective trial of bilevel versus continuous positive airway pressure in acute pulmonary edema. Cardiac and respiratory effects of continuous positive airway pressure and noninvasive ventilation in acute cardiac pulmonary edema Noninvasive pressure support ventilation vs. continuous positive airway pressure in acute hypercapnic pulmonary edema Continuous positive airway pressure and supplemental oxygen in the treatment of cardiogenic pulmonary edema. Noninvasive pressure support ventilation (NIPSV) with face mask in patients with acute cardiogenic pulmonary edema (ACPE) Boussignac continuous positive airway pressure device in the emergency care of acute cardiogenic pulmonary oedema: a randomized pilot study The efficacy of early continuous positive airway pressure therapy in patients with acute cardiogenic pulmonary edema. Randomised controlled comparison of continuous positive airways pressure, bilevel non-invasive ventilation, and standard treatment in emergency department patients with acute cardiogenic pulmonary oedema Oxygen therapy, continuous positive airway pressure, or noninvasive bilevel positive pressure ventilation in the treatment of acute cardiogenic pulmonary edema. Predictors of failure of noninvasive positive pressure ventilation in patients with acute hypoxemic respiratory failure: a multi-center study Randomised controlled trial of continuous positive airway pressure and standard oxygen therapy in acute pulmonary oedema; effects on plasma brain natriuretic peptide concentrations. High-dose intravenous isosorbide-dinitrate is safer and better than Bi-PAP ventilation combined with conventional treatment for severe pulmonary edema. Reappraisal of continuous positive airway pressure therapy in acute cardiogenic pulmonary edema. Short-term results and long-term follow-up. Continuous positive airway pressure by face mask in acute cardiogenic pulmonary edema. The Effect of Nasal Continuous Positive Airway Pressure on Plasma Endothelin-1 Concentrations in Patients with Severe Cardiogenic Pulmonary Edema Myocardial infarction rate in acute pulmonary edema: Noninvasive pressure support ventilation versus continuous positive airway pressure Randomized, prospective trial of oxygen, continuous positive airway pressure, and bilevel positive airway pressure by face mask in acute cardiogenic pulmonary edema* Treatment of severe cardiogenic pulmonary edema with continuous positive airway pressure delivered by face mask.
Objective To compare the physiological effects and the clinical efficacy of continuous positive airway pressure ( CPAP ) vs st and ard medical treatment in elderly patients ( ≥75 years ) with acute hypoxemic respiratory failure related to cardiogenic pulmonary edema . Design A prospect i ve , r and omized , 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 r and omly assigned to receive st and ard medical treatment alone ( n=46 ) or st and ard 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 st and ard 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/FIO2 , 306±104 vs 157±71 ; p=0.004 ) compared with baseline , whereas no differences were observed within the st and ard treatment group . Severe complications occurred in 17 patients in the st and ard 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 st and ard 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 OBJECTIVE To evaluate the utility of bilevel positive airway pressure ( BiPAP ) in the out-of-hospital treatment of patients with presumed congestive heart failure ( CHF ) . METHODS This was a prospect i ve , sequential , parallel trial in an urban setting served by a single emergency medical services ( EMS ) system between January 4 and April 15 , 1999 . A convenience sampling of adults who were transported by rescue units judged to be in CHF by treating emergency medical technicians trained in advanced life support ( ALS EMTs ) was included . Rescue squads were divided into demographically matched pairs , and one of each was equipped with a BiPAP ventilatory support unit . Bilevel positive airway pressure therapy was added to the existing treatment protocol s for eligible study patients . Main outcome measures were out-of-hospital treatment time , oxygen saturation changes , hospitalization length , need for endotracheal intubation , mortality rate , and ease of use of the device by EMS personnel . RESULTS Sixty-two of 71 enrolled patients completed the study .  Out-of-hospital treatment times did not differ between groups ( 31.2 minutes vs 31.4 minutes ; p = 0.931 ) . The difference between pre- and post-treatment oxygen saturation levels was greater for the BiPAP group ( 13.71 % ) than the control group ( 6.69 % ) ( p < 0.05 ) . There was no statistical difference between groups in the length of hospital stay [ control : 7.63 days , vs BiPAP : 6.33 days , p = 0.48 ] , the intubation rate [ control : 7 of 25 ( 28 % ) vs BiPAP : 4 of 37 ( 11 % ) , p = 0.10 ] , or death rate [ control : 2 of 24 , vs BiPAP : 6 of 37 , p = 0.46 ] . All of the ALS EMTs who used BiPAP thought that it was safe to use , and 97 % thought it was easy and appeared to improve patients ' dyspnea and respiratory distress . CONCLUSIONS ALS EMTs can be trained to deliver noninvasive ventilation with BiPAP , find it easy to apply , and believe that it helps relieve dyspnea in patients with suspected CHF OBJECTIVE To evaluate whether bilevel positive airway pressure , by actively assisting inhalation , more rapidly improves ventilation , acidemia , and dyspnea than continuous positive airway pressure ( CPAP ) in patients with acute pulmonary edema . DESIGN R and omized , controlled , double-blind trial . SETTING Emergency department in a university hospital . PATIENTS Twenty-seven patients , presenting with acute pulmonary edema , characterized by dyspnea , tachypnea , tachycardia , accessory muscle use , bilateral rales , and typical findings of congestion on a chest radiograph . INTERVENTIONS In addition to st and ard therapy , 13 patients were r and omized to receive nasal CPAP ( 10 cm H2O ) , and 14 patients were r and omized to receive nasal bilevel positive airway pressure ( inspiratory and expiratory positive airway pressures of 15 and 5 cm H2O , respectively ) in the spontaneous/timed mode that combines patient flow-triggering and backup time-triggering . MEASUREMENTS AND MAIN RESULTS After 30 mins , significant reductions in breathing frequency ( 32 + /- 4 to 26 + /- 5 breaths/min ) , heart rate ( 110 + /- 21 to 97 + /- 20 beats/min ) , blood pressure ( mean 117 + /- 28 to 92 + /- 18 mm Hg ) , and Paco2 ( 56 + /- 15 to 43 + /- 9 torr [ 7.5 + /- 2 to 5.7 + /- 1.2 kPa ] ) were observed in the bilevel positive airway pressure group , as were significant improvements in arterial pH and dyspnea scores ( p < .05 for all of these parameters ) . Only breathing frequency improved significantly in the CPAP group ( 32 + /- 4 to 28 + /- 5 breaths/min , p < .05 ) . At 30 mins ; the bilevel positive airway pressure group had greater reductions in Paco2 ( p = .057 ) , systolic blood pressure ( p = .005 ) , and mean arterial pressure ( p = .03 ) than the CPAP group . The myocardial infa rct ion rate was higher in the bilevel positive airway pressure group ( 71 % ) compared with both the CPAP group ( 31 % ) and historically matched controls ( 38 % ) ( p = .05 ) . Duration of ventilator use , intensive care unit and hospital stays , and intubation and mortality rates were similar between the two groups . CONCLUSIONS Bilevel positive airway pressure improves ventilation and vital signs more rapidly than CPAP in patients with acute pulmonary edema . The higher  rate  of myocardial infa rct ions associated with the use of bilevel positive airway pressure highlights the need for further studies to clarify its effects on hemodynamics and infa rct ion rates , and to determine optimal pressure setting Objective Continuous positive airway pressure ( CPAP ) is considered an effective nonpharmacologic method of treating patients with severe acute cardiogenic pulmonary edema . However , we hypothesized that bilevel noninvasive positive-pressure ventilation ( NPPV ) , which combines both inspiratory pressure support and positive expiratory pressure , would unload the respiratory muscles and improve cardiac and hemodynamic function more effectively than CPAP . Design R and omized crossover study . Setting Critical care unit , Raymond Poincaré Hospital . Patients Six consecutive patients with acute cardiogenic pulmonary edema . Interventions Patients were sequentially treated with 5 cm H2O CPAP , 10 cm H2O CPAP , and NPPV in a r and om order . Measurements and Main Results Cardiac and hemodynamic function and indexes of respiratory mechanics were measured at each treatment sequence . NPPV reduced the esophageal pressure swing and esophageal pressure-time product compared with baseline ( p < .05 ) . There was no reduction in esophageal pressure swing or esophageal pressure-time product with CPAP . NPPV and 10 cm H2O CPAP reduced the mean transmural right and left atrial filling pressures without a change in cardiac index . Conclusions This study demonstrates that NPPV was more effective at unloading the respiratory muscles than CPAP in acute cardiogenic pulmonary edema . In addition , NPPV and 10 cm H2O CPAP produced a reduction in right and left ventricular preload , which suggests an improvement in cardiac performance 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 R and omized prospect i ve study in an emergency department . Patients and participants We r and omly 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 The efficacy of continuous positive airway pressure ( CPAP ) administered with a face mask was compared to oxygen supplementation in 40 patients with acute cardiogenic pulmonary edema . Baseline arterial blood gas values and pH , heart rate , respiratory rate , and blood pressure were recorded after patients breathed 28 percent oxygen with an ambient airway pressure for ten minutes . Thereafter , inspired oxygen concentration ( FIO2 ) was increased by 0.10 and airway pressure was increased by 10 cm H2O in r and om sequence . Cardiopulmonary function was reassessed after a five-minute stabilization period at each level of oxygen supplementation and airway pressure . An increase in FIO2 and the application of CPAP both produced significant elevation in arterial blood oxygen tension . Use of CPAP was consistently associated with a decrease in respiratory rate , blood pressure , and rate pressure product , which were not observed with a mere enhancement of oxygen therapy . The improvement in the measured cardiopulmonary variables associated with CPAP therapy can not be achieved by reversing hypoxemia with supplemental oxygen only 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 , prospect i ve 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 infa rct ion ( 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 This study aim ed 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 prospect ively studied 30 consecutive patients with acute cardiogenic pulmonary oedema . They were r and omly assigned either to the Boussignac-CPAP valve , which delivered oxygen , or to st and ard 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 st and ard 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 Although continuous positive airway pressure ( CPAP ) therapy using a face mask is known to improve oxygenation , the intrapulmonary shunt reduction remains unsettled . Our study was design ed to explore this issue . From 1985 to 1987 80 patients with acute cardiogenic pulmonary edema were r and omly chosen to receive either serial CPAP therapy or high-flow face mask oxygen therapy without CPAP ( control ) for the purpose of evaluating the efficacy of CPAP therapy . After screening for exclusion , only 55 patients were included in the first 3-hour investigation period . PaO2 in the CPAP group showed a significant increase by the end of the initial study ; whereas intrapulmonary shunt and alveolar-arterial oxygen tension gradient AaDO2 revealed simultaneously a significant reduction . Conversely , neither PaO2 nor intrapulmonary shunt ( or AaDO2 ) in the control group demonstrated any significant beneficial changes . As for cardiovascular function , only the CPAP therapy achieved a significant reduction in rate pressure product in contrast to the control ( face mask ) therapy alone . In terms of therapeutic failure , 10 patients in the control group failed . However , in the CPAP group only 5 patients had failed at the end of the first 3-hour study period . Overall , the cumulative therapeutic failure rate was 28 % in the CPAP group and 60 % in the control group during a 6-hour observation study . However , there was no significant difference between the two groups in 24-hour hospital mortality . ( ABSTRACT TRUNCATED AT 250 WORDS 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 r and omised comparison with st and ard oxygen therapy . Methods : Sixty patients presenting with acidotic ( pH<7.35 ) acute , cardiogenic pulmonary oedema , were r and omly assigned conventional oxygen therapy , CPAP ( 10 cm H2O ) , or bilevel ventilation ( IPAP 15 cm H2O , EPAP 5 cm H2O ) provided by a st and ard 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 OBJECTIVE To compare the effects of 3 types of noninvasive respiratory support systems in the treatment of acute pulmonary edema :  oxygen therapy ( O2 ) , continuous positive airway pressure , and bilevel positive pressure ventilation . METHODS We studied prospect ively 26 patients with acute pulmonary edema , who were r and omized into 1 of 3 types of respiratory support groups . Age was 69+/-7 years . Ten patients were treated with oxygen , 9 with continuous positive airway pressure , and 7 with noninvasive bilevel positive pressure ventilation . All patients received medicamentous therapy according to the Advanced Cardiac Life Support protocol . Our primary aim was to assess the need for orotracheal intubation .  We also assessed the following : heart and respiration rates , blood pressure , PaO2 , PaCO2 , and pH at beginning , and at 10 and 60 minutes after starting the protocol . RESULTS At 10 minutes , the patients in the bilevel positive pressure ventilation group had the highest PaO2 and the lowest respiration rates ; the patients in the O2 group had the highest PaCO2 and the lowest pH ( p<0.05 ) . Four patients in the O2 group , 3 patients in the continuous positive pressure group , and none in the bilevel positive pressure ventilation group were intubated ( p<0.05 ) . CONCLUSION Noninvasive bilevel positive pressure ventilation was effective in the treatment of acute cardiogenic pulmonary edema , accelerated the recovery of vital signs and blood gas data , and avoided intubation Abstract . Context : In patients with hypoxemic acute respiratory failure ( ARF ) , r and omized studies have shown noninvasive positive pressure ventilation ( NPPV ) to be associated with lower rates of endotracheal intubation . In these patients , predictors of NPPV failure are not well characterized . Objective : To investigate variables predictive of NPPV failure in patients with hypoxemic ARF . Design : Prospect i ve , multicenter cohort study . Setting : Eight Intensive Care Units ( ICU ) in Europe and USA . Patients : Of 5,847 patients admitted between October 1996 and December 1998 , 2,770 met criteria for hypoxemic ARF . Of these , 2,416 were already intubated and 354 were eligible for the study . Results : NPPV failed in 30 % ( 108/354 ) of patients . The highest intubation rate was observed in patients with ARDS ( 51 % ) or community-acquired pneumonia ( 50 % ) . The lowest intubation rate was observed in patients with cardiogenic pulmonary edema ( 10 % ) and pulmonary contusion ( 18 % ) . Multivariate analysis identified age > 40 years ( OR 1.72 , 95 % CI 0.92–3.23 ) , a simplified acute physiologic score ( SAPS II ) ≥35 ( OR 1.81 , 95 % CI 1.07–3.06 ) , the presence of ARDS or community-acquired pneumonia ( OR 3.75 , 95 % CI 2.25–6.24 ) , and a PaO2:FiO2 ≤146 after 1 h of NPPV ( OR 2.51 , 95 % CI 1.45–4.35 ) as factors independently associated with failure of NPPV . Patients requiring intubation had a longer duration of ICU stay ( P<0.001 ) , higher rates of ventilator-associated pneumonia and septic complications ( P<0.001 ) , and a higher ICU mortality ( P<0.001 ) . Conclusions : In hypoxemic ARF  , NPPV can be successful in selected population s. When patients have a higher severity score , an older age , ARDS or pneumonia , or fail to improve after 1 h of treatment , the risk of failure is higher AIMS The study aim was to compare the effects of continuous positive airway pressure ( CPAP ) on clinical outcomes and plasma neurohormonal concentrations in patients with acute pulmonary oedema . METHODS AND RESULTS In addition to st and ard therapy , 58 consecutive patients were r and omized to receive 60 % inhaled oxygen with or without CPAP  at 7.5 cmH(2)O pressure . Clinical variables , symptoms and oxygenation were monitored and plasma epinephrine , norepinephrine and brain natriuretic peptide ( BNP ) concentrations estimated at 0 , 1 , 6 and 24 h. CPAP was associated with less breathlessness at 1 h ( P<0.001 ) , no treatment failures and more rapid resolution in respiratory rate ( P<0.001 ) , heart rate ( P<0.001 ) and acidosis ( P<0.005 ) . Length of hospital stay was similar but there was a trend for a reduction in overall hospital mortality in the CPAP group ( 0.10>P>0.05 ) . Plasma BNP concentrations rose progressively ( P<0.001 ) before falling below admission concentrations at 24 h. Plasma neurohumoral concentrations were unaffected by CPAP treatment but were elevated in patients who died or had acute myocardial infa rct ion . CONCLUSION CPAP produces a more rapid clinical and symptomatic improvement in patients with acute pulmonary oedema , particularly within the first hour . CPAP is a useful adjunctive treatment in the early management of acute heart failure OBJECTIVE To determine the feasibility , safety and efficacy of bilevel positive airway ventilation ( BiPAP ) in the treatment of severe pulmonary edema compared to high dose nitrate therapy . BACKGROUND Although noninvasive ventilation is increasingly used in the treatment of pulmonary edema , its efficacy has not been compared prospect ively with newer treatment modalities . METHODS We enrolled 40 consecutive patients with severe pulmonary edema ( oxygen saturation < 90 % on room air prior to treatment ) . All patients received oxygen at a rate of 10 liter/min , intravenous ( IV ) furosemide 80 mg and IV morphine 3 mg . Thereafter patients were r and omly allocated to receive 1 ) repeated boluses of IV isosorbide-dinitrate ( ISDN ) 4 mg every 4 min ( n = 20 ) , and 2 ) BiPAP ventilation and st and ard dose nitrate therapy ( n = 20 ) . Treatment was administered until oxygen saturation increased above 96 % or systolic blood pressure decreased to below 110 mm Hg or by more than 30 % . Patients whose conditions deteriorated despite therapy were intubated and mechanically ventilated . All treatment was delivered by mobile intensive care units prior to hospital arrival . RESULTS Patients treated by BiPAP had significantly more adverse events . Two BiPAP treated patients died versus zero in the high dose ISDN group . Sixteen BiPAP treated patients ( 80 % ) required intubation and mechanical ventilation compared to four ( 20 % ) in the high dose ISDN group ( p = 0.0004 ) . Myocardial infa rct ion ( MI ) occurred in 11 ( 55 % ) and 2 ( 10 % ) patients , respectively ( p = 0.006 ) . The combined primary end point ( death , mechanical ventilation or MI ) was observed in 17 ( 85 % ) versus 5 ( 25 % ) patients , respectively ( p = 0.0003 ) . After 1 h of treatment , oxygen saturation increased to 96 + /- 4 % in the high dose ISDN group as compared to 89 + /- 7 % in the BiPAP group ( p = 0.017 ) . Due to the significant deterioration observed in patients enrolled in the BiPAP arm , the study was prematurely terminated by the safety committee . CONCLUSIONS High dose ISDN is safer and better than BiPAP ventilation combined with conventional therapy in patients with severe pulmonary edema To investigate whether serial incremental continuous positive airway pressure ( CPAP ) has any short-term or long-term advantages over face-mask oxygen therapy by way of intrapulmonary shunt reduction , 100 patients admitted to the coronary care unit for the treatment of acute cardiogenic pulmonary edema were studied . All patients received Swan-Ganz catheterization . Hemodynamic and pulmonary function parameters were recorded over the next 6 h , and the patients were followed until hospital discharge . All survivors received regular follow-up at 1-month intervals in the outpatient clinic . During the first-stage investigation period ( 3 h ) PaO2 in the CPAP group showed a significant increase , whereas the intrapulmonary shunt and alveolar-arterial oxygen tension gradient ( P[A-a]O2 ) was significantly reduced ( p < 0.005 ) . The CPAP group had significantly lower rate-pressure product and higher stroke volume index compared with the control group . The therapeutic failure rate over 6 h was 24 % in the CPAP group and 50 % in the control group ( p < 0.01 ) . The CPAP group had a significantly lower incidence of tracheal intubation and ventilator therapy than the control group ; however , there was no significant difference in short-term mortality and hospital stay between the two groups . In conclusion , although study size was not large enough to demonstrate a difference in mortality , CPAP therapy result ed in physiologic cardiovascular and pulmonary function improvement and significantly reduced the need for intubation ; however , it did not decrease mortality in patients with acute cardiogenic pulmonary edema , and a much larger study is needed to investigate this possibility The therapeutic efficacy of continuous positive airway pressure ( CPAP ) administered by face mask was studied in 40 patients with acute cardiogenic pulmonary edema and respiratory failure .  Arterial blood gas values and pH , systemic arterial pressure , heart rate and respiratory rate were measured during administration of 30 % oxygen with a high-flow face mask apparatus at ambient airway pressure . Twenty patients were then r and omly chosen to continue ambient airway pressure breathing and 20 received 10 cm H2O of CPAP . The measurements were repeated 10 , 60 and 180 minutes after therapy was initiated . During the first 10 minutes of CPAP treatment , arterial blood oxygen partial pressure increased 8 + /- 9 mm Hg ( mean + /- 1 st and ard deviation ) , ( p less than 0.01 ) and respiratory rate decreased 5 + /- 5 breaths/min ( p less than 0.001 ) . Systolic arterial pressure decreased 12 + /- 21 mm Hg ( p less than 0.05 ) , and heart rate by 10 + /- 11 beats/min ( p less than 0.001 ) . A decrease in respiratory rate by 2 + /- 5 breaths/min ( p less than 0.05 ) was the only change that occurred in the control group . The improvement in arterial blood oxygenation persisted throughout the investigation period ( p less than 0.05 ) . Thirteen patients ( 65 % ) in the control group and 7 patients ( 35 % ) in the CPAP group met our criteria for treatment failure during the study ( p = 0.068 ) . Thus , CPAP administered by face mask improves gas exchange , decreases respiratory work , unloads circulatory stress , and may reduce the need for ventilator treatment in acute cardiogenic pulmonary edema We investigated the effects of nasal continuous positive airway pressure ( CPAP ) on plasma endothelin-1 ( ET-1 ) concentrations in patients with cardiogenic pulmonary edema . Thirty patients were r and omly assigned to two groups : 15 patients who received oxygen plus nasal CPAP ( CPAP group ) , and 15 patients who received only oxygen by face mask ( oxygen group ) . The heart rate and the mean pulmonary artery pressure decreased significantly in the CPAP group . The PaO2/fraction of inspired oxygen ( FIO2 ) ratio increased in the CPAP group ( 163 + /- 70 to 332 + /- 104 , P < 0.01 ) after 6 h and was significantly higher than that in the oxygen group . Arterial plasma ET-1 concentrations decreased from 6.2 + /- 2.0 pg/mL to 4.8 + /- 1.7 pg/mL ( P < 0.05 ) after 6 h and to 3.3 + /- 0.7 pg/mL ( P < 0.01 ) after 24 h in the CPAP group . Arterial plasma ET-1 concentrations in the CPAP group compared with the oxygen group were significantly lower at 24 h. There was a correlation between the arterial plasma ET-1 concentrations and mean pulmonary artery pressure ( r = 0.62 , P < 0.001 ) , and PaO2/FIO2 ( r = -0.46 , P < 0.01 ) . Nasal CPAP led to an early decrease in plasma ET-1 concentrations , and improvement in oxygenation and hemodynamics . ( Anesth Analg 1997;84:1091 - 6 Objective : Noninvasive pressure support ventilation ( NIPSV ) delivered by face mask has proved an effective treatment for patients with acute pulmonary edema . However , an increase in acute myocardial infa rct ion rate has been reported with this ventilation modality . We investigated whether the use of NIPSV increases the incidence of acute myocardial infa rct ion compared with continuous positive airway pressure ( CPAP ) in patients with acute pulmonary edema . Design : R and omized , prospect i ve , controlled study . Setting : Emergency Department , Niguarda Hospital of Milano ( Italy ) . Patients : Forty-six patients affected by acute pulmonary edema . Interventions : The patients received either NIPSV ( 24 patients ) or CPAP ( 22 patients ) through a face mask . Measurements and Main Results : Cardiac enzymes ( myoglobin , creatine kinase isoenzyme MB , and troponin I ) were determined and electrocardiographic and physiologic measurements made over the subsequent 36 hrs . No significant differences were observed in the incidence of acute myocardial infa rct ion in the CPAP group ( 13.6 % ) compared with the NIPSV group ( 8.3 % ) . Both modalities of noninvasive ventilation improved ventilation and vital signs in patients with acute pulmonary edema . Two patients of the NIPSV group ( 8.3 % ) and one of the CPAP group ( 4.5 % ) required endotracheal intubation because vital signs and arterial blood gases worsened 1 hr after the start of noninvasive ventilation . No significant differences were found in in-hospital mortality rate . Conclusions : NIPSV proved to be equally effective in improving vital signs and ventilation without increasing acute myocardial infa rct ion rate in patients with nonischemic acute pulmonary edema in comparison to CPAP alone . However , because the study lacked statistical power and excluded patients with acute coronary syndromes , caution is still advised when applying NIPSV to the latter subgroup of patients 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 : R and omized , controlled trial . Setting : Tertiary hospital emergency room . Patients : We r and omly assigned 80 patients with severe cardiogenic acute pulmonary edema into three treatment groups . Patients were followed for 60 days after the r and omization . 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 result ed 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 infa rct ion 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 result ed 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 BACKGROUND Severe cardiogenic pulmonary edema is a frequent cause of respiratory failure , and many patients with this condition require endotracheal intubation and mechanical ventilation . We investigated whether continuous positive airway pressure delivered by means of a face mask had physiologic benefit and would reduce the need for intubation and mechanical ventilation . METHODS We r and omly assigned 39 consecutive patients with respiratory failure due to severe cardiogenic pulmonary edema to receive either oxygen alone or oxygen plus continuous positive airway pressure delivered through a face mask . It was not possible to blind the investigators to the assigned treatment . Physiologic measurements were made over the subsequent 24 hours , and the patients were followed to hospital discharge . RESULTS After 30 minutes , both respiratory rate and arterial carbon dioxide tension had decreased more in the patients who received oxygen plus continuous positive airway pressure . The mean ( + /- SD ) respiratory rate at 30 minutes decreased from 32 + /- 6 to 33 + /- 9 breaths per minute in the patients receiving oxygen alone and from 35 + /- 8 to 27 + /- 6 breaths per minute in those receiving oxygen plus continuous positive airway pressure ( P = 0.008 ) ; the arterial carbon dioxide tension decreased from 64 + /- 17 to 62 + /- 14 mm Hg in those receiving oxygen alone and from 58 + /- 8 to 46 + /- 4 mm Hg in those receiving oxygen plus continuous positive airway pressure ( P less than 0.001 ) . The patients receiving continuous positive airway pressure also had a greater increase in the arterial pH  ( oxygen alone , from 7.15 + /- 0.11 to 7.18 + /- 0.18 ; oxygen plus continuous positive airway pressure , from 7.18 + /- 0.08 to 7.28 + /- 0.06 ; P less than 0.001 ) and in the ratio of arterial oxygen tension to the fraction of inspired oxygen  ( oxygen alone , from 136 + /- 44 to 126 + /- 47 ; oxygen plus continuous positive airway pressure , from 138 + /- 32 to 206 + /- 126 ; P = 0.01 ) . After 24 hours , however , there were no significant differences between the two treatment groups in any of these respiratory indexes . Seven ( 35 percent ) of the patients who received oxygen alone but none who received oxygen plus continuous positive airway pressure required intubation and mechanical ventilation ( P = 0.005 ) . However , no significant difference was found in in-hospital mortality  ( oxygen alone , 4 of 20 patients ; oxygen plus continuous positive airway pressure , 2 of 19 ; P = 0.36 ) or the length of the hospital stay . CONCLUSIONS Continuous positive airway pressure delivered by face mask in patients with severe cardiogenic pulmonary edema can result in early physiologic improvement and reduce the need for intubation and mechanical ventilation . This short-term study could not establish whether continuous positive airway pressure has any long-term benefit or whether a larger study would have shown a difference in mortality between the treatment groups
CONTEXT In patients with acute cardiogenic pulmonary edema  noninvasive ventilation may reduce intubation rate , but the impact on mortality and the superiority of one technique over another have not been clearly established .
OBJECTIVE To systematic ally review and quantitatively synthesize the short-term effect of noninvasive ventilation on major clinical outcomes .