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

Abstract

Background: Continuous positive airways pressure (CPAP) and bilevel non-invasive ventilation may have beneficial effects in the treatment of patients with acute cardiogenic pulmonary oedema. The efficacy of both treatments was assessed in the UK emergency department setting, in a randomised comparison with standard oxygen therapy. Methods: Sixty patients presenting with acidotic (pH,7.35) acute, cardiogenic pulmonary oedema, were randomly assigned conventional oxygen therapy, CPAP (10 cm H 2 O), or bilevel ventilation (IPAP 15 cm H 2 O, EPAP 5 cm H 2 O) provided by a standard ventilator through a face mask. The main end points were treatment success at two hours and in-hospital mortality. Analyses were by intention to treat. Results: Treatment success (defined as all of respiratory rate,23 bpm, oxygen saturation of.90%, and arterial blood pH.7.35 (that is, reversal of acidosis), at the end of the two hour study period) occurred in three (15%) patients in the control group, seven (35%) in the CPAP group, and nine (45%) in the bilevel group (p = 0.116). Fourteen (70%) of the control group patients survived to hospital discharge, compared with 20 (100%) in the CPAP group and 15 (75%) in the bilevel group (p = 0.029; Fisher's test). Conclusions: In this study, patients presenting with acute cardiogenic pulmonary oedema and acidosis, were more likely to survive to hospital discharge if treated with CPAP, rather than with bilevel ventilation or with conventional oxygen therapy. There was no relation between in hospital survival and early physiological changes. Survival rates were similar to other studies despite a low rate of endotracheal intubation.

Is helmet CPAP first line pre-hospital treatment of presumed severe acute pulmonary edema?

“…This result compares favourably with the study by Kosowsky et al, reporting an in hospital intubation rate of 7 out of 19 (37%). Intubation rate and overall mortality of the present study is in line with recent reports on the in-hospital [4,[7][8][9][10]27] and out-hospital [12] application of CPAP and Pressure Support Ventilation in ACPE. Oxygen saturation improved, respiratory rate, heart rate, and blood pressure decreased in both groups.…”

“…[2][3][4][5][6][7][8][9][10]. Despite this background, reports of CPAP application in prehospital setting are, to our knowledge quite limited.…”

“…In hospital, non-invasive Continuous Positive Airway pressure (CPAP) has proven effective in ameliorating gas exchange and reducing both the need for endotracheal intubation and the overall mortality of patients with ACPE, as suggested by randomized controlled trials and a recent meta-analysis [2][3][4][5][6][7][8][9][10], although this result has been challenged by a large multicenter trial. [11] With the understanding that immediate advanced medical care is essential to improve the long-term outcome of cardiac patients, we developed a program for the pre-hospital application of CPAP.…”

“…The correct application of face masks is therefore somehow difficult even in an Intensive Care Unit (ICU) or in the Emergency Room (ER), and it may be very problematic or ineffective in the pre-hospital setting. 4 We therefore selected the helmet for prehospital CPAP application: it appears to be as effective as face mask [16], easily applied, well tolerated and clinically beneficial [14,17,18].…”

Bi-level Versus Continuous Positive Airway Pressure in Acute Cardiogenic Pulmonary Edema: A Randomized Control Trial

“…Many studies revealed that, CPAP improved arterial oxygenation (PaO 2 ), and reduces endotracheal intubation rate [9][10][11] and mortality rate in ACPE [12,13]. However, other studies failed to show these effects [14][15][16].…”