Brief ReportsRandomized Trial of Bilevel versus Continuous Positive Airway Pressure for Acute Pulmonary Edema
Section snippets
Introductions
Multiple randomized controlled studies and meta-analyses have demonstrated the efficacy of either continuous positive airway pressure (CPAP) or noninvasive positive pressure ventilation (NPPV) (i.e., the combination of positive end expiratory pressure and pressure support administered via a face mask) to treat acute cardiogenic pulmonary edema (APE) 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18. When compared with standard oxygen and medical therapy, these modalities more
Methods
The study was approved by Rhode Island Hospital’s institutional review board. Written informed consent was obtained from either the patient or the proxy prior to study enrollment and randomization.
Results
From a total of 150 screened patients with a presumed diagnosis of APE, 36 were enrolled. Nineteen patients were randomized to CPAP and 17 patients were randomized to BPAP. Of the remaining 114 patients, 42 patients had a diagnosis other than APE (chronic obstructive pulmonary disease exacerbation [n = 25], pneumonia [n = 7], asthma exacerbation [n = 7], pulmonary embolism [n = 1], idiopathic pulmonary fibrosis [n = 1], and obstructive sleep apnea [n = 1]); 26 had a respiratory rate ≤24; 15
Discussion
Our findings indicate that, contrary to our previous study, patients with APE treated with BPAP do not have higher MI rates than those treated with CPAP (19). Furthermore, BPAP more rapidly improves oxygenation and dyspnea scores in these patients, compared to CPAP therapy. Perhaps related to these more rapid improvements, fewer BPAP than CPAP patients required ICU admission.
Although both CPAP and BPAP have demonstrated improved outcomes in APE patients when compared to oxygen therapy alone,
Conclusions
In this follow-up study to the Mehta study on APE that found a strong trend for increased MI rate in a BPAP compared to a CPAP group, we found no indication that MI rate was increased in either group (19). This contrary finding is most likely related to better randomization, improved methods to detect and exclude patients with MIs upon ED presentation, and advances in BPAP device technology. BPAP manifested early advantages over CPAP with regard to resolution of dyspnea and better oxygenation,
Acknowledgments
The authors are very grateful for the assistance of the Department of Respiratory Care at Rhode Island Hospital, who were very helpful in identifying possible candidates for the study and collecting data.
Oronasal masks connected to BPAP were donated by Respironics, Inc.
Nicholas S. Hill, MD, received a research grant from Breathe Technologies.
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Cited by (27)
Utility of non-invasive synchronized intermittent mandatory ventilation in acute cardiogenic pulmonary edema
2022, American Journal of Emergency MedicineCitation Excerpt :Despite the differences in data, the fact that all patients showed similar clinical improvement supports this idea. Looking at the relevant literature, previous studies and reviews have recommended bilevel modes and especially modes that contain frequency support for patients with hypercarbia and high dyspnea scores, wherein the modes were shown to increase oxygenation further [3,13]. Although there is no clear meta-analysis or systematic review on this topic, the above recommendations support the decisions of the practitioners in this study.
Dyspnea in Patients Receiving Mechanical Ventilation
2021, Encyclopedia of Respiratory Medicine, Second EditionNon-Invasive Mechanical Ventilation Versus Continuous Positive Airway Pressure in Cardiogenic Pulmonary Edema in an Intensive Care Unit
2019, Archivos de BronconeumologiaManagement of Heart Failure in the Emergency Department Setting: An Evidence-Based Review of the Literature
2018, Journal of Emergency MedicineCitation Excerpt :These patients are typically euvolemic, with minimal peripheral edema and acute onset on presentation, with symptoms due to fluid maldistribution rather than fluid overload (45,46). NIPPV increases intrathoracic pressure, thereby decreasing preload and lowering pulmonary interstitial fluid, as well as decreasing the work of breathing (38–40). NIPPV can be provided as continuous positive airway pressure or bi-level positive airway pressure (41,42).