title: Randomized, prospective trial of bilevel versus continuous positive airway pressure in acute pulmonary edema.
abstract: OBJECTIVE
  To evaluate whether bilevel positive airway pressure, by actively assisting inhalation, more rapidly improves ventilation, acidemia, and dyspnea than continuous positive airway pressure (CPAP) in patients with acute pulmonary edema.
  
  
  METHODS
  Randomized, controlled, double-blind trial.
  
  
  METHODS
  Emergency department in a university hospital.
  
  
  METHODS
  Twenty-seven patients, presenting with acute pulmonary edema, characterized by dyspnea, tachypnea, tachycardia, accessory muscle use, bilateral rales, and typical findings of congestion on a chest radiograph.
  
  
  METHODS
  In addition to standard therapy, 13 patients were randomized to receive nasal CPAP (10 cm H2O), and 14 patients were randomized to receive nasal bilevel positive airway pressure (inspiratory and expiratory positive airway pressures of 15 and 5 cm H2O, respectively) in the spontaneous/timed mode that combines patient flow-triggering and backup time-triggering.
  
  
  RESULTS
  After 30 mins, significant reductions in breathing frequency (32 +/- 4 to 26 +/- 5 breaths/min), heart rate (110 +/- 21 to 97 +/- 20 beats/min), blood pressure (mean 117 +/- 28 to 92 +/- 18 mm Hg), and Paco2 (56 +/- 15 to 43 +/- 9 torr [7.5 +/- 2 to 5.7 +/- 1.2 kPa]) were observed in the bilevel positive airway pressure group, as were significant improvements in arterial pH and dyspnea scores (p < .05 for all of these parameters). Only breathing frequency improved significantly in the CPAP group (32 +/- 4 to 28 +/- 5 breaths/min, p < .05). At 30 mins; the bilevel positive airway pressure group had greater reductions in Paco2 (p = .057), systolic blood pressure (p = .005), and mean arterial pressure (p = .03) than the CPAP group. The myocardial infarction rate was higher in the bilevel positive airway pressure group (71%) compared with both the CPAP group (31%) and historically matched controls (38%) (p = .05). Duration of ventilator use, intensive care unit and hospital stays, and intubation and mortality rates were similar between the two groups.
  
  
  CONCLUSIONS
  Bilevel positive airway pressure improves ventilation and vital signs more rapidly than CPAP in patients with acute pulmonary edema. The higher rate of myocardial infarctions associated with the use of bilevel positive airway pressure highlights the need for further studies to clarify its effects on hemodynamics and infarction rates, and to determine optimal pressure settings.
authors.affiliation: Division of Pulmonary Medicine, Rhode Island Hospital, Providence 02903, USA.
authors.forename: S
authors.initials: S
authors.lastname: Mehta
authors.forename: G D
authors.initials: GD
authors.lastname: Jay
authors.forename: R H
authors.initials: RH
authors.lastname: Woolard
authors.forename: R A
authors.initials: RA
authors.lastname: Hipona
authors.forename: E M
authors.initials: EM
authors.lastname: Connolly
authors.forename: D M
authors.initials: DM
authors.lastname: Cimini
authors.forename: J H
authors.initials: JH
authors.lastname: Drinkwine
authors.forename: N S
authors.initials: NS
authors.lastname: Hill
mesh_terms: D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D004311:Double-Blind Method; D005260:Female; D006439:Hemodynamics; D006801:Humans; D007442:Intubation, Intratracheal; D008297:Male; D009203:Myocardial Infarction / Q000209:etiology; D011175:Positive-Pressure Respiration / Q000009:adverse effects / Q000379:methods; D011446:Prospective Studies; D011654:Pulmonary Edema / Q000503:physiopathology / Q000628:therapy*; D012119:Respiration; D012121:Respiration, Artificial / Q000295:instrumentation / Q000379:methods*; D012189:Retrospective Studies; D015300:Ventilator Weaning