Original ContributionContinuous positive airway pressure for cardiogenic pulmonary edema: a randomized study☆,☆☆
Introduction
Acute cardiogenic pulmonary edema (ACPE) is a frequent presenting disease for acute out-of-hospital practice. Acute left ventricular failure may occur from a variety of processes that rapidly deteriorates to this generalized cardiopulmonary disorder. The classical treatment of out-of-hospital ACPE includes supplemental oxygen, vasodilators, and loop diuretics. If not effective or because of the associated respiratory depression, tracheal intubation and mechanical ventilation are often needed, which, by themselves are associated with a worse prognosis [1]. Bilevel positive airway pressure (BiPAP) and continuous positive airway pressure (CPAP) has been proposed to avoid mechanical ventilation in severe ACPE [2], [3], [4], [5], [6]. The overall effect of CPAP in the acute management of ACPE is to improve cardiorespiratory function and sustained tissue oxygenation. This technique not only decreases intrapulmonary shunt [6] and work of breathing [7] but also reduces left ventricular afterload and both right and left ventricular preload [8]. Collectively, the available data suggest that CPAP is effective in reduction in intubation rate and that there is a trend toward reduced mortality in emergency departments [9]. Some randomized prospective trials [10], [11], [12] have demonstrated significant improvements in vital signs and gas exchange as well as drastic reductions in intubation rates attributable to the use of CPAP. In patients with ACPE, with no effect on short-term mortality. However, the evidence for CPAP in the out-of-hospital setting is limited only to several case series, nonrandomized studies, and few randomized studies [13], [14], [15], [16], [17], [18], [19], [20], [21]. One randomized study focused on severe respiratory distress with paramedic-staffed ambulances [20], and another study focused on immediate effects on early vs late CPAP in a prehospital setting with physician-staffed ambulances [21]. To our knowledge, no study focused on ACPE in a prehospital setting compared CPAP to a placebo treatment, and no study was focused on delayed effects of CPAP vs usual care for ACPE (eg, later than in-hospital death). The purpose of this study was then to determine whether out-of-hospital treatment with CPAP improves significantly respiratory distress for patients in ACPE.
Section snippets
Study design
This prospective, randomized, controlled, nonblinded trial was registered with ClinicalTrials.gov (identifier NCT00439075). Enrollment began in September 2006 and finished when the desired number of patients was reached in March 2008. The regional ethics committee (Toulouse II, France) approved this study, with exception to preliminary written informed consent. Patients meeting eligibility criteria were read a standard statement that briefly explained the nature of the study, and if they (or
Results
One hundred ninety consecutive ACPE were screened between September 2006 and March 2008. One hundred twenty-four patients were enrolled in the study (Fig. 1). Sixty-two patients were randomly assigned to usual care and 62 to CPAP. No patient was enrolled in the study twice. The 2 groups had similar baseline characteristics (see Table 1), with a nonsignificant trend toward a difference in the rate of previous ACPE between the 2 groups (45% in the usual care group vs 30% in the CPAP group; P =
Discussion
Our study was designed to ascertain that the known mechanisms by which CPAP works in ACPE would result in an improved outcome in addition to usual care in a medical prehospital setting. In the present study, when adding CPAP in one group, patients did not exhibit significantly less symptoms of respiratory fatigue. Moreover, intubation rate, overall mortality, and hospital length of stay were equally distributed in the 2 treatment groups. There are still controversial studies in the literature;
Conclusion
In the prehospital setting, in spite of its potential advantages for patients in ACPE, CPAP may not be preferred to a strict optimal treatment including low-dose morphine, furosemide, oxygen, and high-dose boluses of isosorbide dinitrate unrestricted according to clinical response.
References (25)
- 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.
Continuous and bilevel positive airway pressure in the treatment of acute cardiogenic pulmonary edema
Am J Emerg Med
(2000) - et al.
Effect of non-invasive positive pressure ventilation (NIPPV) on mortality in patients with acute cardiogenic pulmonary oedema: a meta-analysis
Lancet
(2006) - et al.
Continuous positive airway pressure and supplemental oxygen in the treatment of cardiogenic pulmonary edema
Chest
(1987) - et al.
Prehospital use of continuous positive airway pressure (CPAP) for presumed pulmonary edema: a preliminary case series
Prehosp Emerg Care
(2001) - et al.
Treatment of severe decompensated heart failure with high-dose intravenous nitroglycerin: a feasibility and outcome analysis
Ann Emerg Med
(2007) - et al.
High-dose intravenous isosorbide dinitrate is safer and better than Bi-PAP ventilation combined with conventional treatment for severe pulmonary edema
J Am Coll Cardiol
(2000) - et al.
Association of noninvasive ventilation with nosocomial infections and survival in critically ill patients
JAMA
(2000) - et al.
Treatment of severe cardiogenic pulmonary edema with continuous positive airway pressure delivered by face mask
N Engl J Med
(1991)
A comparison of continuous and bilevel positive airway pressure non-invasive ventilation in patients with acute cardiogenic pulmonary oedema: a meta-analysis
Crit Care
Ventilatory and hemodynamic effects of continuous positive airway pressure in left heart failure
Am J Respir Crit Care Med
Cited by (26)
Early diagnosis of atrial fibrillation using a E-health application
2019, American Journal of Emergency MedicineReply to statistical errors in a recent article in the journal
2015, Journal of Emergency MedicineEffect of out-of-hospital noninvasive positive-pressure support ventilation in adult patients with severe respiratory distress: A systematic review and meta-analysis
2014, Annals of Emergency MedicineCitation Excerpt :Six of the 7 included trials used CPAP in the treatment arm of the study14-18,20 and 1 used BiPAP.19 Four different commercial NIPPV systems were used to generate positive pressure, including an external pressure regulator (WhisperFlow,14,18 Downflow16), turbulent flow valve (Boussignac15), and portable ventilator (Oxylog 300017,19,20). Although analysis is beyond the scope of this review, each system has its strengths and weaknesses with respect to ease of paramedic use, cost, maximum therapy length because of oxygen requirements, and compatibility with existing hospital hardware.27
Assessment of the addition of prehospital continuous positive airway pressure (CPAP) to an urban emergency medical services (EMS) system in persons with severe respiratory distress
2013, Journal of Emergency MedicineCitation Excerpt :Similar to findings on hospital LOS, recent investigations on the effect of prehospital CPAP on mortality also have been inconsistent (38,43,47,48). Our findings are consistent with recent studies that did not demonstrate significant differences in 7- and 30-day mortality when comparing patients receiving standard oxygen therapy and those undergoing non-invasive ventilation (47,48). Interestingly, Gray et al. did not find a difference in mortality between those receiving standard oxygen therapy and those undergoing non-invasive ventilation (9.8% vs. 9.5%, respectively; p = 0.87) despite patients undergoing non-invasive ventilation for a minimum of 2 h (48).
Non-Invasive Ventilation in the Prehospital Emergency Setting: A Systematic Review and Meta-Analysis
2023, Prehospital Emergency Care
- ☆
Work attributed to: SAMU 31. CHU Purpan. Toulouse, France.
- ☆☆
Support: The authors have no commercial associations or sources of support that might pose a conflict of interest. Support was provided solely by institutional sources; this work was sponsored by the University Hospital of Toulouse for regulatory and ethic submission.