Chest

Chest

Volume 127, Issue 3, March 2005, Pages 1053-1058
Journal home page for Chest

Selected Reports
Does Continuous Positive Airway Pressure by Face Mask Improve Patients With Acute Cardiogenic Pulmonary Edema Due to Left Ventricular Diastolic Dysfunction?

https://doi.org/10.1378/chest.127.3.1053Get rights and content

Objective

Continuous positive airway pressure (CPAP) by face mask is an effective method of treating severe cardiogenic pulmonary edema (CPE). However, to our knowledge, no study has provided a precise evaluation of the effects of CPAP on cardiac function in patients presenting with CPE and preserved left ventricular (LV) function

Design

Prospective observational clinical study

Setting

A 14-bed, medical ICU at a university hospital

Patients

Nine consecutive patients presenting with hypoxemic acute CPE

Interventions

All patients were selected for 30 min of CPAP with 10 cm H2O by mask with fraction of inspired oxygen adjusted for a cutaneous saturation > 90%. Doppler echocardiography was performed before CPAP application and during the last 10 min of breathing with CPAP. Two-tailed, paired t-tests were used to compare data recorded at baseline (oxygen alone) and after CPAP

Measurements and results

Four patients presented CPE with preserved left ventricular (LV) function (a preserved LV ejection fraction [LVEF] > 45%, and/or aortic velocity time integral > 17 cm in the absence of aortic stenosis or hypertrophic cardiomyopathy). Oxygenation and ventilatory parameters were improved by CPAP in all patients. Hemodynamic monitoring and Doppler echocardiographic analysis demonstrated that in patients with preserved LV systolic function, mean arterial pressure and LV end-diastolic volume were decreased significantly by CPAP (p < 0.04). In patients with LV systolic dysfunction, CPAP improved LVEF (p < 0.05) and decreased LV end-diastolic volume (p = 0.001) significantly

Conclusion

CPAP improves oxygenation and ventilatory parameters in all kinds of CPE. In patients with preserved LV contractility, the hemodynamic benefit of CPAP results from a decrease in LV end-diastolic volume (preload)

Section snippets

Materials and Methods

The protocol was approved by the hospital institutional ethical board, and no informed consent was required before entering the study, as CPAP is a part of routine therapeutic practice applied to CPE. Over a 6-month period, this study of nine patients with acute CPE was performed in a medical ICU. The criteria for entering the study included clinical signs of hypoxemic CPE with dyspnea, orthopnea, and radiologic evidence of pulmonary congestion on chest radiography despite pharmacologic

Results

During 6 months, 13 patients met the study criteria. Four patients were excluded for the following reasons: atrial fibrillation (n = 2), tachycardia > 120 beats/min (n = 1), and hemodynamic instability (n = 1). The protocol was conducted in nine patients with CPE (six men and three women; mean age, 65 years; range, 34 to 93 years). Six patients had a medical history of hypertensive cardiomyopathy, and three patients had coronary diseases. No patients presenting with acute CPE had

Discussion

The present study shows that in all types of CPE, CPAP by mask improves oxygenation and decreases RR. In patients with LV diastolic dysfunction, the hemodynamic benefit of CPAP results from a decrease in LV end-diastolic volume (preload). However, in patients with altered systolic function, the utility of CPAP is due to both an increase in LVEF and a decrease in preload.

LV diastolic dysfunction is defined as an impaired ventricular filling and is the mechanism of diastolic heart failure with

Acknowledgments

We thank Prof. Claude Guerin, University of Lyon (France), for his helpful suggestions during the planning phase of the study, and Samia Brunner for translation support.

References (39)

  • J Rasanen et al.

    Continuous positive airway pressure by face mask in acute cardiogenic pulmonary edema

    Am J Cardiol

    (1985)
  • AD Bersten et al.

    Treatment of severe cardiogenic pulmonary edema with continuous positive airway pressure delivered by face mask

    N Engl J Med

    (1991)
  • M Lin et al.

    Reappraisal of continuous positive airway pressure therapy in acute cardiogenic pulmonary edema: short-term results and long-term follow-up

    Chest

    (1995)
  • F Lenique et al.

    Ventilatory and hemodynamic effects of continuous positive airway pressure in left heart failure

    Am J Respir Crit Care Med

    (1997)
  • GP Aurigemma et al.

    Reduced left ventricular systolic pump performance and depressed myocardial contractile function in patients > 65 years of age with normal ejection fraction and a high relative wall thickness

    Am J Cardiol

    (1995)
  • C Delclaux et al.

    Treatment of acute hypoxemic nonhypercapnic respiratory insufficiency with continuous positive airway pressure delivered by a face mask: a randomized controlled trial

    JAMA

    (2000)
  • RO Bonow et al.

    Left ventricular diastolic dysfunction as a cause of congestive heart failure: mechanisms and management

    Ann Intern Med

    (1992)
  • Cohen-A Solal et al.

    A national survey of heart failure in French hospitals. The Myocardiopathy and Heart Failure Working Group of the French Society of Cardiology, the National College of General Hospital Cardiologists and the French Geriatrics Society

    Eur Heart J

    (2000)
  • MR Zile et al.

    New concepts in diastolic dysfunction and diastolic heart failure: Part I. Diagnosis, prognosis, and measurements of diastolic function

    Circulation

    (2002)
  • K Bendjelid et al.

    Treatment of respiratory failure with noninvasive continuous positive airway pressure

    JAMA

    (2001)
  • MM Redfield et al.

    Burden of systolic and diastolic ventricular dysfunction in the community: appreciating the scope of the heart failure epidemic

    JAMA

    (2003)
  • MT Naughton et al.

    Effect of continuous positive airway pressure on intrathoracic and left ventricular transmural pressures in patients with congestive heart failure

    Circulation

    (1995)
  • RD Branson et al.

    Mask CPAP: state of the art

    Respir Care

    (1985)
  • NB Schiller et al.

    Recommendations for quantitation of the left ventricle by two-dimensional echocardiography. American Society of Echocardiography Committee on Standards, Subcommittee on Quantitation of Two-Dimensional Echocardiograms

    J Am Soc Echocardiogr

    (1989)
  • JG Cleland et al.

    Management of heart failure in primary care (the IMPROVEMENT of Heart Failure Programme): an international survey

    Lancet

    (2002)
  • RS Vasan et al.

    Defining diastolic heart failure: a call for standardized diagnostic criteria

    Circulation

    (2000)
  • M Senni et al.

    Heart failure with preserved systolic function: a different natural history?

    J Am Coll Cardiol

    (2001)
  • RS Vasan et al.

    Prevalence, clinical features and prognosis of diastolic heart failure: an epidemiologic perspective

    J Am Coll Cardiol

    (1995)
  • SR Ommen et al.

    A clinical approach to the assessment of left ventricular diastolic function by Doppler echocardiography: update 2003

    Heart

    (2003)

    • Cited by (0)

    Preliminary data have been presented to the Fifteenth International Congress of Echocardiography. June 11–13, 2003, Paris, France. This study was been performed at the medical ICU of Lyon-Sud, and was supported by the Gold Medal fund of Lyon University Hospitals (Dr. Bendjelid), Lyon, France

    View full text
    Copyright © 2005 The American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.