Prehospital use of continuous positive airway pressure (CPAP) for presumed pulmonary edema: a preliminary case series. Noninvasive continuous positive airway pressure in elderly cardiogenic pulmonary edema patients Use of bilevel positive airway pressure in out-of-hospital patients. Effect of nasal continuous positive airway pressure on pulmonary edema complicating acute myocardial infarction. Cardiac and respiratory effects of continuous positive airway pressure and noninvasive ventilation in acute cardiac pulmonary edema A pilot prospective, randomized, placebo-controlled trial of bilevel positive airway pressure in acute asthmatic attack. A randomized study of out-of-hospital continuous positive airway pressure for acute cardiogenic pulmonary oedema: physiological and clinical effects. Effectiveness of Prehospital Continuous Positive Airway Pressure in the Management of Acute Pulmonary Edema Continuous positive airway pressure and supplemental oxygen in the treatment of cardiogenic pulmonary edema. CPAP for acute cardiogenic pulmonary oedema from out-of-hospital to cardiac intensive care unit: a randomised multicentre study Randomised controlled comparison of continuous positive airways pressure, bilevel non-invasive ventilation, and standard treatment in emergency department patients with acute cardiogenic pulmonary oedema Prehospital noninvasive pressure support ventilation for acute cardiogenic pulmonary edema Oxygen therapy, continuous positive airway pressure, or noninvasive bilevel positive pressure ventilation in the treatment of acute cardiogenic pulmonary edema. Prehospital use of continuous positive airway pressure for acute severe congestive heart failure. Randomised controlled trial of continuous positive airway pressure and standard oxygen therapy in acute pulmonary oedema; effects on plasma brain natriuretic peptide concentrations. Non-invasive pressure support ventilation versus conventional oxygen therapy in acute cardiogenic pulmonary oedema: a randomised trial Low–Fractional Oxygen Concentration Continuous Positive Airway Pressure is Effective in the Prehospital Setting Reappraisal of continuous positive airway pressure therapy in acute cardiogenic pulmonary edema. Short-term results and long-term follow-up. T HE U SE OF P REHOSPITAL C ONTINUOUS P OSITIVE A IRWAY P RESSURE T REATMENT IN P RESUMED A CUTE S EVERE P ULMONARY E DEMA ‘Boussignac’ continuous positive airway pressure system: practical use in a prehospital medical care unit Continuous positive airway pressure by face mask in acute cardiogenic pulmonary edema. Treatment of presumed acute cardiogenic pulmonary oedema in an ambulance system by nurses using Boussignac continuous positive airway pressure An observational study of noninvasive positive pressure ventilation in an out-of-hospital setting. Early out-of-hospital non-invasive ventilation is superior to standard medical treatment in patients with acute respiratory failure: a pilot study The Effect of Nasal Continuous Positive Airway Pressure on Plasma Endothelin-1 Concentrations in Patients with Severe Cardiogenic Pulmonary Edema Randomized, prospective trial of oxygen, continuous positive airway pressure, and bilevel positive airway pressure by face mask in acute cardiogenic pulmonary edema* Continuous positive airway pressure for cardiogenic pulmonary edema: a randomized study. Treatment of severe cardiogenic pulmonary edema with continuous positive airway pressure delivered by face mask.
OBJECTIVE To describe the prehospital use of a continuous positive airway pressure ( CPAP ) system for the treatment of acute respiratory failure presumed to be due to cardiogenic pulmonary edema . METHODS Prospect i ve case-series analysis . Paramedics administered CPAP via face mask at 10 cm H2O to patients believed to be in cardiogenic pulmonary edema and in imminent need of endotracheal intubation ( ETI ) . Data from run sheets and hospital records were analyzed for treatment intervals , vital signs , complications , admitting diagnoses , need for ETI , and mortality . RESULTS Nineteen patients received prehospital CPAP therapy .  Mean duration of therapy was 15.5 minutes . Pre- and post-therapy pulse oximetry  was available for 15 patients and demonstrated an increase from a mean of 83.3 % to a mean of 95.4 % . None of the patients were intubated in the field . Two patients who did not tolerate the CPAP mask required ETI upon arrival in the emergency department ( ED ) ; an additional five patients required ETI within 24 hours . There was one death in the series and two additional adverse events ( one aspiration pneumonia , one pneumothorax ) ; none of these were attributable to the use of CPAP . The diagnosis of cardiogenic pulmonary edema was corroborated by the ED or in-hospital physician in 13 patients ( 68 % ) . Paramedics reported no technical difficulties with the CPAP system . CONCLUSION For patients with acute respiratory failure and presumed pulmonary edema , the prehospital use of CPAP is feasible and may avert the need for ETI . Future controlled studies are needed to assess the utility and cost-effectiveness of prehospital CPAP systems 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 Cardiogenic pulmonary edema is a frequent cause of reparatory failure . We investigated the effects of nasal continuous positive airway pressure ( CPAP ) in patients with severe pulmonary edema associated with acute myocardial infa rct ion . Twenty-nine consecutive patients were divided into 3 groups : firstly , 7 intubated patients who received mechanical ventilation at study entry comprised the intubation group . The rest of the patients were r and omly assigned to either of the following 2 groups : 11 patients who received oxygen plus CPAP delivered by a nasal mask ( CPAP group ) , and 11 patients who received oxygen only via face mask ( oxygen group ) . All patients in the intubation group had cardiogenic shock . Two patients ( 18 % ) in the CPAP group and 8 patients ( 73 % ) in the oxygen group required mechanical ventilation with endotracheal intubation ( p=0.03 ) . The hospital mortality rate in the CPAP group ( 9 % ) was significantly lower than the oxygen group ( 64 % , p=0.02 ) . The pulmonary artery wedge pressure and heart rate were significantly lower in the CPAP group than in the oxygen group 24 h after study entry ( p<0.05 and p<0.01 ) . The mean pulmonary artery pressure 48 h after study entry was 18+/-5 mmHg in the CPAP group and 25+/-8 mmHg in the oxygen group ( p<0.05 ) . The PaO2/FiO2 ratio increased in the intubation group ( 168+/-69 to 240+/-57 , p<0.05 ) and the CPAP group ( 137+/-17 to 253+/-67 , p<0.01 ) 24 h after study entry . Arterial plasma endothelin-1 concentrations decreased significantly earlier in the CPAP group than in the oxygen group ( p<0.05 ) . In patients without cardiogenic shock , nasal CPAP lead to an early improvement in oxygenation and hemodynamics , and decreased the mortality rate . Early and active respiratory management is recommended in patients with pulmonary edema associated with acute myocardial infa rct ion 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 STUDY OBJECTIVE Noninvasive ventilation has been shown to be effective in patients with acute respiratory failure due to pulmonary edema and exacerbations of COPD . Its role in an acute asthmatic attack , however , is uncertain . The purpose of this pilot study was to compare conventional asthma treatment with nasal bilevel pressure ventilation ( BPV ) [ BiPAP ; Respironics ; Murrysville , PA ] plus conventional treatment in patients with a severe asthmatic attack admitted to the emergency department . DESIGN A prospect i ve , r and omized , placebo-controlled study . SETTING An emergency department at a university hospital . PATIENTS Thirty patients with a severe asthma attack were recruited from a larger group of 124 asthmatic patients seen in the emergency department . Fifteen patients were r and omly assigned to BPV plus conventional therapy and 15 patients to conventional therapy alone . The two groups had similar clinical characteristics on hospital admission . Mean ( + /- SD ) FEV(1 ) on recruitment was 37.3 + /- 10.7 % in the BPV group and 33.8 + /- 10.2 % in the control group ( p = not significant ) . INTERVENTIONS AND MEASUREMENTS BPV with predetermined inspiratory and expiratory pressures was applied for 3 h in the BPV group ; in the control group , a similar sham device with subtherapeutic pressures was applied for 3 h. Bedside lung function test results and vital signs were obtained at baseline , and during and at the completion of the study protocol . RESULTS The use of BPV significantly improved lung function test results . Eighty percents of the patients in the BPV group reached the predetermined primary end points ( an increase of at least 50 % in FEV(1 ) as compared to baseline ) , vs 20 % of control patients ( p < 0.004 ) . Mean rise in FEV(1 ) was 53.5 + /- 23.4 % in the BPV group and 28.5 + /- 22.6 % in the conventional treatment group ( p = 0.006 ) . The intention-to-treat analysis of the secondary end point rate of hospitalization included 33 patients . Hospitalization was required for 3 of 17 patients ( 17.6 % ) in the BPV group , as compared with 10 of 16 patients ( 62.5 % ) in the control group ( p = 0.0134 ) . CONCLUSION In selected patients with a severe asthma attack , the addition of BPV to conventional treatment can improve lung function , alleviate the attack faster , and significantly reduce the need for hospitalization AIMS In acute cardiogenic pulmonary oedema ( ACPE ) , continuous positive airway pressure ( CPAP ) added to medical treatment improves outcome . The present study was design ed to assess the benefit of CPAP as a first line treatment of ACPE in the out-of-hospital environment . METHODS AND RESULTS The protocol lasted 45 min , divided into three periods of 15 min . Patients with ACPE were r and omly assigned in two groups : 1/Early CPAP ( n = 63 ) :  CPAP alone ( T0-T15 ) ; CPAP + medical treatment ( T15-T30 ) ; medical treatment alone ( T30-T45 ) and 2/Late CPAP ( n = 61 ) : medical treatment alone ( T0-T15 ) ; medical treatment + CPAP ( T15-T30 ) ; medical treatment alone ( T30-T45 ) . Primary endpoint : effect of early CPAP on a dyspnoea clinical score and on arterial blood gases . Secondary endpoints : incidence of tracheal intubation , inotropic support , and in-hospital mortality . T0-T15 : CPAP alone had a greater effect than medical treatment on the clinical score ( P = 0.0003 ) and on PaO(2 ) ( P = 0.0003 ) . T15-T30 : adding CPAP to medical treatment ( late CPAP group ) improved clinical score and blood gases and the two groups were no longer different at T30 . T30-T45 : in both groups , CPAP withdrawal worsened clinical score . Six patients in ' early CPAP ' group vs. 16 in ' late CPAP ' group were intubated [ P = 0.01 , odds-ratio : OR = 0.30 ( 0.09 - 0.89 ) ] . Dobutamine was used only in the ' late CPAP ' group ( n = 5 ) , ( P = 0.02 ) . Hospital death was higher in ' late CPAP ' group ( n = 8) than in ' early CPAP ' group ( n = 2 ) [ P = 0.05 , OR = 0.22 ( 0.04 - 1.0 ) ] . CONCLUSION When compared to usual medical care , immediate application of CPAP alone in out-of-hospital treatment of ACPO is significantly better improving physiological variables and symptoms and significantly reduces tracheal intubation incidence and in-hospital mortality Objective . To compare the effectiveness of continuous positive airway pressure ( CPAP ) with st and ard pharmacologic treatment in the management of prehospital acute pulmonary edema . Methods . Using a nonr and omized control group design , all consecutive patients presenting to two participating emergency medical services ( EMS ) systems with a field impression of acute pulmonary edema between July 1 , 2004 , and June 30 , 2005 , were included in the study . The control EMS system patients received st and ard treatment with oxygen , nitrates , furosemide , morphine , and , if indicated , endotracheal intubation . The intervention EMS system patients received CPAP via face mask at 10 cm H2O in addition to st and ard therapy . Results . Ninety-five patients received st and ard therapy , and 120 patients received CPAP and st and ard therapy .  Intubation was required in 8.9 % of CPAP-treated patients compared with 25.3 % in the control group ( p = 0.003 ) , and mortality was lower in the CPAP group than in the control group ( 5.4 % vs. 23.2 % ; p = 0.000 ) . When compared with the control group , the CPAP group had more improvement in respiratory rate ( −4.55 vs. −1.81 ; p = 0.001 ) , pulse rate ( −4.77 vs. 0.82 ; p = 0.013 ) , and dyspnea score ( −2.11 vs. −1.36 ; p = 0.008 ) . Using logistic regression to control for potential confounders , patients receiving st and ard treatment were more likely to be intubated ( odds ratio , 4.04 ; 95 % confidence interval , 1.64 to 9.95 ) and more likely to die ( odds ratio , 7.48 ; 95 % confidence interval , 1.96 to 28.54 ) than those receiving st and ard therapy and CPAP . Conclusion . The prehospital use of CPAP is feasible , may avert the need for endotracheal intubation , and may reduce short-term mortality 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 Purpose Continuous positive airway pressure ( CPAP ) is a useful treatment for patients with acute cardiogenic pulmonary oedema ( CPE ) . However , its usefulness in the out-of-hospital setting has been poorly investigated and only by small and single-centre studies . We design ed a multicentre r and omised study to assess the benefit of CPAP initiated out of hospital . Methods A total of 207 patients with CPE were r and omly allocated by emergency mobile medical units to receive either st and ard treatment alone or st and ard treatment plus CPAP . CPAP was maintained after admission to the intensive care unit ( ICU ) . Inclusion criteria were orthopnoea , respiratory rate greater than 25 breaths/min , pulse oximetry less than 90 % in room air and diffuse crackles . The primary end point was assessed during the first 48 h and combined : death , presence of intubation criteria , persistence of either all inclusion criteria or circulatory failure at the second hour or their reappearance before 48 h. Absence of all criteria defined successful treatment . Results CPAP was used for 60 min [ 40 , 65 ] ( median [ Q1 , Q3 ] ) in the pre-hospital setting and 120 min [ 60 , 242 ] in ICU and was well tolerated in all patients . Treatment was successful in 79 % of patients in the CPAP group and 63 % in the control group ( p = 0.01 ) , especially for persistence of inclusion criteria after 2 h ( 12 vs. 26 % ) and for intubation criteria ( 4 vs. 14 % ) . CPAP was beneficial irrespective of the initial PaCO2 or left ventricular ejection fraction . Conclusion Immediate use of CPAP in out-of-hospital treatment of CPE and until CPE resolves after admission significantly improves early outcome compared with medical treatment alone 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 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 prospect i ve r and omized trial . All patients received st and ard 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 % ; st and ard=89.5±2.7 % , P=0.002 ) . A trend toward higher troponin T levels was seen in the st and ard 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 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 BACKGROUND The utility of continuous positive airway pressure ( CPAP ) in the in-hospital treatment of congestive heart failure ( CHF ) is well established . Its exact role is less clear in the prehospital arena . OBJECTIVE To describe the prehospital use of CPAP for patients presenting with acute severe heart failure in a large Emergency Medical Services system in New Jersey . METHODS Retrospective review of prehospital charts from January 1 , 2005 to December 31 , 2006 of patients treated for acute CHF . Inclusion criteria for eligibility for CPAP mask use were : respiratory rate > 25 breaths/min , labored and shallow breathing , bilateral rales , history of CHF , intact mental status , and prehospital clinical diagnosis of CHF . Data collected included demographics , vital signs , oxygen saturation ( SaO(2 ) ) , need for endotracheal intubation ( ETI ) , and complications . RESULTS There were 1306 charts review ed ; 387 patients met inclusion criteria . Of the 387 , 149 patients had placement of CPAP ( 38.5 % ) . The prehospital treatment times were ( CPAP = 30 min ; non-CPAP = 31 min ; p < 0.01 ) . The increase in SaO(2 ) for the CPAP group ( 9 % ) vs. the non-CPAP group ( 5 % ) was statistically significant ( p < 0.01 ) . Systolic blood pressure ( BP ) reduction ( CPAP [ 27.1 mm Hg ] , non-CPAP [ 19.9 mm Hg ] , p < 0.01 ) , diastolic BP reduction ( CPAP [ 14.1 mm Hg ] , non-CPAP [ 7.4 mm Hg ] , p < 0.01 ) , heart rate reduction ( CPAP [ 17.2 beats/min ] , non-CPAP [ 9.6 beats/min ] , p < 0.01 ) , respiratory rate reduction ( CPAP [ 5.63 ] , non-CPAP [ 4.09 ] , p < 0.01 ) , and ETI reduction ( CPAP [ 2.6 % ] , non-CPAP [ 5.46 % ] , p < 0.01 ) , all were statistically significant . Adjunctive CHF treatments were similar between the groups . CONCLUSION The use of CPAP for eligible patients with acute severe CHF seems to be feasible and beneficial . Large-scale r and omized prospect i ve prehospital studies are needed to vali date these results 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 BACKGROUND Non-invasive pressure support ventilation ( NIPSV ) is an effective treatment for acute respiratory failure in patients with chronic obstructive pulmonary disease . We assessed the efficacy of this therapy in acute cardiogenic pulmonary oedema in a r and omised comparison with conventional oxygen therapy . METHODS 40 patients were r and omly assigned conventional oxygen therapy or NIPSV supplied by a st and ard ventilator through a face mask , with adjustment of tidal volume and pressure support in addition to a positive end-expiratory pressure of 5 cm water . Physiological measurements were obtained in the first 2 h and at 3 h , 4 h , and 10 h. The main endpoints were intubation rate and resolution time . Analyses were by intention to treat . FINDINGS Three patients were withdrawn on the basis of clinical and chest radiography results . Endotracheal intubation was required in one ( 5 % ) of 19 patients assigned NIPSV and in six ( 33 % ) of 18 assigned conventional oxygen therapy ( p=0.037 ) . Resolution time ( defined as a clinical improvement with oxygen saturation of 96 % or more and respiratory rate less than 30 breaths/min ) was significantly shorter in the NIPSV group ( median 30 [ IQR 15 - 53 ] vs 105 [ 50 - 230 ] min , p=0.002 ) . NIPSV led to a rapid improvement in oxygenation in the first 2 h. There were no differences in hospital length of stay or mortality . INTERPRETATION In this study of acute cardiogenic pulmonary oedema , NIPSV was superior to conventional oxygen therapy . Further studies should compare NIPSV with continuous positive airway pressure Abstract Objective . The objective of this study was to determine the effects of low – fractional concentration of inspired oxygen ( FiO2 ) continuous positive airway pressure ( CPAP ) in prehospital noninvasive ventilation ( NIV ) . With increasing concerns about the detrimental effects of hyperoxia , we sought to determine whether CPAP using a low FiO2 ( 28%–30 % ) was effective in the prehospital setting . Methods . The study was a six-month prospect i ve , nonblinded observational study conducted in a large , busy urban emergency medical services ( EMS ) system ( Las Vegas , NV ) . Results . A total of 340 patients participated in the study . Most patients presented with symptoms consistent with a diagnosis of congestive heart failure/acute pulmonary edema ( 47.4 % ) , followed by chronic obstructive pulmonary disease ( COPD ) ( 40.9 % ) , asthma ( 22.7 % ) , and pneumonia ( 15.9 % ) . Improvements were seen in respiratory rate ( p = 0.00 ) and oxygen saturation ( p = 0.00 ) . The overall CPAP discontinuation rate was 16.5 % . The most common reason for CPAP discontinuation was anxiety/claustrophobia . The total number of patients requiring prehospital intubation was 5.6 % . Subjective paramedic assessment of patient status at hospital delivery found that 71.5 % of patients ’ conditions were improved , 15.1 % remained unchanged , and 13.4 % were worse . Conclusions . CPAP using a low FiO2 ( 28%–30 % ) was highly effective in the treatment of commonly encountered prehospital respiratory emergencies 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 Objective . To describe the prehospital use of a continuous positive airway pressure ( CPAP ) system for the treatment of presumed acute severe pulmonary edema ( ASPE ) . Methods . The efficacy of prehospital CPAP treatment was analyzed in terms of changes in oxygen saturation , need for intubation or ventilatory support , and possible morbidity associated with the CPAP therapy . This was a retrospective cohort study conducted in the mobile intensive care unit of a university hospital . Participants included all consecutive patients with a clinical picture of ASPE treated by a mobile intensive care unit between January 1 , 1998 , and December 31 , 1999 . Results . 121 patients were included in this study . 116 patients received prehospital CPAP therapy .  Two patients ( 1.7 % ) from the CPAP-treated patients were intubated in the field . A total of six patients required  endotracheal intubation  before hospital , and six other patients after that . After the beginning of CPAP treatment , there was statistically significant elevation in blood oxygen saturation ( mean and st and ard deviation [ SD ] before CPAP 77 % ± 11 % and after CPAP 90 % ± 7 % ) ( p < 0.0001 ) as well as reductions in the respiratory rate ( mean and SD before CPAP 34 ± 8 breaths/min and after CPAP 28 ± 8 breaths/min ) ( p < 0.0001 ) , systolic blood pressure ( mean and SD before CPAP 173 ± 39 mm Hg and after CPAP 166 ± 37 mm Hg ) ( p = 0.0002 ) , and heart rate ( mean and SD before CPAP 108 ± 25 beats/min and after CPAP 100 ± 20 beats/min ) ( p = 0.0017 ) . The main reason for in-hospital death ( 8 % ) was myocardial infa rct ion . No technical problems or complications occurred during CPAP treatment . Conclusions . Prehospital CPAP treatment in patients with ASPE improved oxygenation significantly and lowered respiratory rate , heart rate , and systolic blood pressure . Because of the retrospective nature of this study , the hemodynamic effects of nitroglycerine and morphine can not be excluded . The mortality rate was low , which needs to be confirmed in a controlled , prospect i ve study Continuous positive airway pressure in acute cardiogenic pulmonary edema is rarely used by prehospital emergency care units , because of the particular technical drawbacks of existing equipment . The aim of this one year prospect i ve descriptive open study without a control group was to assess the technical feasibility of using the Boussignac continuous positive airway pressure system ( Vygon ) in a prehospital medical care service . Statistical comparisons were performed using Student 's t-test or a Wilcoxon T-test . There were 57 decisions to use continuous positive airway pressure . Seven records were excluded . Four patients were intubated on the scene and six within one hour after hospital admission . The respiratory rate and transcutaneous oxygen saturation improved significantly for all of the other patients ( Student 's t-test P < 0.001 ) . The Boussignac continuous positive airway pressure system has many advantages , including flexibility and pressure monitoring , lower oxygen consumption , and ease of use . These should allow this technique to be used more widely by prehospital teams 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 Background : Early initiation of continuous positive airway pressure ( CPAP ) applied by face mask benefits patients with acute cardiogenic pulmonary oedema ( ACPE ) . The simple disposable Boussignac CPAP ( BCPAP ) has been used in ambulances by physicians . In the Netherl and s , ambulances are manned by nurses and not physicians . It was hypothesised that ambulance nurses are able to identify patients with ACPE and can successfully apply BCPAP . A prospect i ve case series of patients with presumed ACPE treated with BCPAP by ambulance nurses is described . Methods : After training of ambulance nurses , all 33 ambulances in the region were equipped with BCPAP . ACPE was diagnosed on clinical signs and pulse oximetry saturation ( Spo2 ) < 95 % . BCPAP ( 5 cm H2O , Fio2 > 80 % ) was generated with an oxygen flow of 15 l/min . The physiological responses , experiences and clinical outcomes of the patients were collected from ambulance and hospital records , and ambulance nurses and patients received a question naire . Results : From March to December 2006 , 32 patients ( age range 61–94 years ) received BCPAP during transport to six different regional hospitals . In 26 patients ( 81 % ) a diagnosis of ACPE was confirmed . With BCPAP , median ( IQR ) Spo2 increased from 79 % ( 69–94 % ) to 96 % ( 89–98 % ) within 20 min . The median ( IQR ) duration of BCPAP treatment was 26 min ( 21–32 ) . The patients had no negative re collection s of the treatment . Ambulance personnel were satisfied with the BCPAP therapy . Conclusion : When applied by ambulance nurses , BCPAP was feasible and effective in improving oxygen saturation in patients with ACPE . Although survival benefit can only be demonstrated by further research , it is considered that BCPAP can be implemented in all ambulances in the Netherl and OBJECTIVE Out-of-hospital clinical experience with noninvasive bilevel positive airway pressure ( BiPAP ) ventilation is extremely limited compared to inhospital management . The aims of this study were to assess the feasibility of out-of-hospital BiPAP ventilation in patients with acute respiratory distress of various origins , and to look for specific factors associated with failure of this respiratory support . METHODS This 2-year prospect i ve observational study assessed the failure rate of  out-of-hospital BiPAP ventilation  , the difficulties encountered , and factors predictive of failure by multivariate analysis . RESULTS Overall , 138 patients were treated by out-of-hospital BiPAP for congestive heart failure ( 56 % ) , chronic obstructive pulmonary disease exacerbation ( 28 % ) , and acute respiratory failure ( 16 % ) . Failure rate was 26 % ( 35/138 ; 95 % confidence interval , 18%-33 % ) ( 11 before and 24 after reaching hospital ) . Independent risk factors were the cause of respiratory distress ( chronic obstructive pulmonary disease exacerbation ; acute respiratory failure ) and an audible air leakage . CONCLUSIONS The failure rate of BiPAP initiated out-of-hospital was no different from previous reports for inhospital failure rates . Failure was attributable to similar causes Objective To assess in patients with acute respiratory failure ( ARF ) whether out-of-hospital ( OOH ) non-invasive ventilation ( NIV ) is feasible , safe and more effective compared with st and ard medical therapy ( SMT ) . Patients and Interventions Patients with OOH ARF were r and omly assigned to receive either SMT or NIV . Measurements and Results Fifty-one patients were enrolled , 26 of whom were r and omly assigned to SMT and 25 of whom received NIV . Two patients were excluded because of protocol violations . OOH NIV was safe and effective in all patients . In the SMT group , treatment was not effective in five of 25 patients who required OOH mechanical ventilation ( p=0.05 ) . Patients in the SMT group were admitted to an intensive care unit ( ICU ) more frequently ( n=17 ) ( p<0.05 ) and for longer periods ( 3.7±6.4 days ) ( p=0.03 ) compared with patients in the NIV group ( n=9 , 1.3±2.6 days ) . Six patients in the SMT group required subsequent inhospital intubation and invasive ventilation during their hospital stays ; only one patient in the NIV group required intubation ( p=0.10 ) . In contrast , patients in the NIV group received NIV more frequently ( n=14 ) in hospital compared with patients in the SMT group ( n=5 ) ( p<0.01 ) . Conclusions OOH NIV proved to be feasible , safe and more effective for the treatment of ARF compared with SMT . OOH NIV promotes inhospital treatment with NIV and may reduce the frequency and length of ICU stays . Because the risks of OOH emergency intubation can be avoided , NIV should be the first-line treatment in OOH ARF if no contraindications are present 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 : 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 STUDY OBJECTIVE The purpose of this r and omized 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 r and omized 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 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
INTRODUCTION Acute respiratory failure ( ARF ) is a common problem encountered by emergency medical services and is associated with significant morbidity , mortality , and health care costs .
Continuous positive airway pressure ( CPAP ) is an integral part of the hospital treatment of acute ARF , predominantly because of congestive heart failure .
Intuitively , better patient outcomes may be achieved when CPAP is applied early in the prehospital setting , but there are few outcome studies to vali date its use in this setting .
OBJECTIVE This systematic review and meta- analysis aim ed to examine the effectiveness of CPAP in the prehospital setting for patients with ARF .