[Effectiveness of nasal positive pressure ventilation in the management of acute refractory left ventricular insufficiency].
BACKGROUND
Ehen refractory to optimal medical treatment cardiogenic pulmonary edema requires mechanical ventilation as a last therapeutic resource. In recent years an increasing number of authors reported their experience in the management of acute or subacute respiratory failure with non-invasive mechanical ventilation by nasal mask.


METHODS
Encouraged by the first promising results reported in literature we experimented this new therapeutic tool in a first group of seven elderly patients (mean age: 76.57--range: 65-89); they all had been admitted for severe cardiogenic pulmonary edema unresponsive to maximal doses of the conventional drugs available for treating acute decompensated heart failure. The enrolled patients were treated with intermittent ventilation administered by nasal mask at selected values of inspiratory positive airway pressure (IPAP) that were comprised between 10 and 20 cm H2O. At the same time an expiratory positive airway pressure (EPAP) at values comprised between 3 and 8 cm H2O was applied. Ventilation was continued for variable periods of 3-24 hours until acceptable values of PaO2 and PaCO2 were obtained. The ventilation modality was spontaneous, spontaneous-time or timed depending on the patients' level of consciousness at starting time.


RESULTS
A good short-term outcome was achieved in all the patients regardless of the ventilation modality applied. The main blood gas alteration was severe hypercapnia with acidosis in three patients, while the other four presented critical hypoxemia unresponsive to simple oxygen supply even if delivered by high-flow Venturi mask. Four of our seven patients were discharged from hospital in satisfactory haemodynamic conditions; the remaining three died during hospitalization from refractory heart failure.


CONCLUSIONS
In this our preliminary experience the therapeutic approach with nasal positive pressure ventilation (NPPV) and EPAP proved to be very effective to improve the signs and symptoms of acute refractory cardiogenic pulmonary edema as it avoided the need of invasive mechanical ventilation. It was well tolerated by all our patients; besides it was not difficult to use or time-consuming for physician and nurses. On the other hand it didn't modify our patients' medium or long-time prognosis which was strictly related to their preexisting left ventricular pump derangement.
Chesi
G
G
Servizio di Cardiologia, USL n. 8-Ospedale di Montecchio E. Reggio Emilia.
Pinelli
G
G
Galimberti
D
D
Navazio
A
A
Montanari
P
P
D000281:Administration, Intranasal; D000368:Aged; D000369:Aged, 80 and over; D002303:Cardiac Output, Low / Q000628:therapy*; D005260:Female; D006801:Humans; D007385:Intermittent Positive-Pressure Ventilation / Q000379:methods; D008297:Male; D011654:Pulmonary Edema / Q000209:etiology* / Q000628:therapy; D012131:Respiratory Insufficiency / Q000628:therapy; D016277:Ventricular Function, Left
Utilità ed efficacia della ventilazione a pressione positiva con maschera nasale nel trattamento dell'insufficienza ventricolare sinistra acuta refrattaria.