ArticlesNon-invasive pressure support ventilation versus conventional oxygen therapy in acute cardiogenic pulmonary oedema: a randomised trial
Introduction
Acute cardiogenic pulmonary oedema is a common cause of acute respiratory failure. During the past decade, several studies have shown that continuous positive airway pressure (CPAP) is effective in this setting, through improvement in gas exchange and decrease in the need for intubation.1, 2, 3 CPAP is usually obtained with a hermetic nasal or face mask that has an expiratory valve to maintain a positive pressure at the end of expiration. With this modality, patients do not receive any assistance with respiration. Non-invasive pressure support ventilation (NIPSV) is a new mode of mechanical ventilation without intubation, in which a certain volume of air is delivered by a ventilator during the inspiratory cycle, by means of a preset pressure and through a nasal or face mask. Addition of positive end-expiratory pressure to NIPSV results in a CPAP mode with an assisted inspiration (also called bilevel positive airway pressure). This assistance can improve ventilation indices and vital signs4, 5 more rapidly than CPAP alone and also seems to reduce the work of breathing more effectively in intubated6 and nonintubated patients.7 In chronic obstructive pulmonary disease, NIPSV reduces the need for endotracheal intubation, the length of stay in the intensive-care unit, and mortality compared with conventional oxygen therapy.8, 9, 10 In patients with acute respiratory failure from other causes, the effect of NIPSV is less conclusive.11, 12, 13 However, good results have been reported,14 especially in hypercapnic patients.15 No study has tested the efficacy of NIPSV over conventional oxygen therapy in acute cardiogenic pulmonary oedema,16 and the available data come from one prematurely stopped trial of bilevel positive airway pressure versus CPAP4 and from uncontrolled studies.17, 18 Therefore, we undertook a controlled prospective randomised study to investigate whether the use of NIPSV would decrease the need for intubation and shorten time to recovery as compared with conventional oxygen therapy in patients with acute cardiogenic pulmonary oedema.
Section snippets
Patients
Our institutional ethics committee approved the study design, and all patients or their next of kin gave written informed consent. We enrolled patients with acute respiratory failure. Inclusion criteria were: dyspnoea of sudden onset with physical findings consistent with pulmonary oedema (widespread rales with or without third heart sound) and typical findings of congestion on a chest radiograph (to initiate treatment as soon as possible, patients could be assigned randomised treatment on
Results
Between April, 1996, and December, 1998, 40 patients were enrolled in the study (figure 1). 102 other patients seen during this period were not included because they did not meet entry criteria. Three patients enrolled were later excluded because they were judged not to have had cardiogenic pulmonary oedema; two were thought to have had pneumonia/bronchopneumonia and one chronic obstuctive pulmonary disease with pulmonary fibrosis. Thus, 19 patients in the NIPSV group and 18 in the control
Discussion
In this study, NIPSV shortened the resolution time of acute cardiogenic pulmonary oedema in comparison with conventional oxygen therapy. This effect could be achieved by several mechanisms: more rapid improvement in oxygenation; more rapid lowering of the respiratory rate, probably as a result of a decrease in the work of breathing; and faster reversal of acidosis (essentially by decreasing hypercapnia). These results are consistent with previous uncontrolled studies of NIPSV in acute
References (28)
- et al.
Continuous positive airway pressure by face mask in acute cardiogenic pulmonary edema
Am J Cardiol
(1985) - et al.
Reappraisal of continuous positive airway pressure therapy in acute cardiogenic pulmonary edema: short-term results and long-term follow-up
Chest
(1995) - et al.
Oxygen cost of breathing in postoperative patients: pressure support ventilation vs continuous positive airway pressure
Chest
(1988) - et al.
Effect of nasal pressure support ventilation and external PEEP on diaphragmatic activity in patients with severe stable COPD
Chest
(1993) - et al.
Early use of non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease on general respiratory wards: a multicentre randomised trial
Lancet
(2000) - et al.
The use of noninvasive positive pressure ventilation in the emergency department: results of a randomized clinical trial
Chest
(1998) - et al.
Noninvasive pressure support ventilation in patients with acute respiratory failure: a randomized comparison with conventional therapy
Chest
(1995) - et al.
Comparison of noninvasive positive pressure ventilation with standard medical therapy in hypercapnic acute respiratory failure
Chest
(1998) - et al.
The effect of positive pressure airway support on mortality and need for intubation in cardiogenic pulmonary edema: a systematic review
Chest
(1998) - et al.
Treatment of severe cardiogenic pulmonary edema with continuous positive airway pressure delivered by face mask
N Engl J Med
(1991)
Randomized, prospective trial of bilevel versus continuous positive airway pressure in acute pulmonary edema
Crit Care Med
Hemodynamic effects of bilevel nasal positive airway pressure ventilation in patients with heart failure
Respiration
Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease
N Engl J Med
Randomized, prospective trial of noninvasive positive pressure ventilation in acute respiratory failure
Am J Respir Crit Care Med
Cited by (368)
Is hypocapnia a risk factor for non-invasive ventilation failure in cardiogenic acute pulmonary edema?
2022, Journal of Critical CareNoninvasive Positive Pressure Ventilation for Acute Decompensated Heart Failure
2020, Heart Failure ClinicsInvasive versus non-invasive ventilation for acute respiratory failure
2023, Research SquareAcute dyspnea in the emergency department: a clinical review
2023, Internal and Emergency Medicine