title: High-dose intravenous isosorbide-dinitrate is safer and better than Bi-PAP ventilation combined with conventional treatment for severe pulmonary edema.
abstract: OBJECTIVE
  To determine the feasibility, safety and efficacy of bilevel positive airway ventilation (BiPAP) in the treatment of severe pulmonary edema compared to high dose nitrate therapy.
  
  
  BACKGROUND
  Although noninvasive ventilation is increasingly used in the treatment of pulmonary edema, its efficacy has not been compared prospectively with newer treatment modalities.
  
  
  METHODS
  We enrolled 40 consecutive patients with severe pulmonary edema (oxygen saturation <90% on room air prior to treatment). All patients received oxygen at a rate of 10 liter/min, intravenous (IV) furosemide 80 mg and IV morphine 3 mg. Thereafter patients were randomly allocated to receive 1) repeated boluses of IV isosorbide-dinitrate (ISDN) 4 mg every 4 min (n = 20), and 2) BiPAP ventilation and standard dose nitrate therapy (n = 20). Treatment was administered until oxygen saturation increased above 96% or systolic blood pressure decreased to below 110 mm Hg or by more than 30%. Patients whose conditions deteriorated despite therapy were intubated and mechanically ventilated. All treatment was delivered by mobile intensive care units prior to hospital arrival.
  
  
  RESULTS
  Patients treated by BiPAP had significantly more adverse events. Two BiPAP treated patients died versus zero in the high dose ISDN group. Sixteen BiPAP treated patients (80%) required intubation and mechanical ventilation compared to four (20%) in the high dose ISDN group (p = 0.0004). Myocardial infarction (MI) occurred in 11 (55%) and 2 (10%) patients, respectively (p = 0.006). The combined primary end point (death, mechanical ventilation or MI) was observed in 17 (85%) versus 5 (25%) patients, respectively (p = 0.0003). After 1 h of treatment, oxygen saturation increased to 96 +/- 4% in the high dose ISDN group as compared to 89 +/- 7% in the BiPAP group (p = 0.017). Due to the significant deterioration observed in patients enrolled in the BiPAP arm, the study was prematurely terminated by the safety committee.
  
  
  CONCLUSIONS
  High dose ISDN is safer and better than BiPAP ventilation combined with conventional therapy in patients with severe pulmonary edema.
authors.affiliation: Department of Medicine, Assaf-Harofeh Medical Center, Zerifin, Israel.
authors.forename: A
authors.initials: A
authors.lastname: Sharon
authors.forename: I
authors.initials: I
authors.lastname: Shpirer
authors.forename: E
authors.initials: E
authors.lastname: Kaluski
authors.forename: Y
authors.initials: Y
authors.lastname: Moshkovitz
authors.forename: O
authors.initials: O
authors.lastname: Milovanov
authors.forename: R
authors.initials: R
authors.lastname: Polak
authors.forename: A
authors.initials: A
authors.lastname: Blatt
authors.forename: A
authors.initials: A
authors.lastname: Simovitz
authors.forename: O
authors.initials: O
authors.lastname: Shaham
authors.forename: Z
authors.initials: Z
authors.lastname: Faigenberg
authors.forename: M
authors.initials: M
authors.lastname: Metzger
authors.forename: D
authors.initials: D
authors.lastname: Stav
authors.forename: R
authors.initials: R
authors.lastname: Yogev
authors.forename: A
authors.initials: A
authors.lastname: Golik
authors.forename: R
authors.initials: R
authors.lastname: Krakover
authors.forename: Z
authors.initials: Z
authors.lastname: Vered
authors.forename: G
authors.initials: G
authors.lastname: Cotter
mesh_terms: D004305:Dose-Response Relationship, Drug; D005260:Female; D006801:Humans; D007275:Injections, Intravenous; D007548:Isosorbide Dinitrate / Q000008:administration & dosage* / Q000009:adverse effects / Q000627:therapeutic use; D008297:Male; D010100:Oxygen / Q000097:blood; D011175:Positive-Pressure Respiration / Q000009:adverse effects / Q000379:methods*; D011654:Pulmonary Edema / Q000097:blood / Q000188:drug therapy / Q000628:therapy*; D016896:Treatment Outcome; D014665:Vasodilator Agents / Q000008:administration & dosage* / Q000009:adverse effects / Q000627:therapeutic use
chemical_list: D014665:Vasodilator Agents; D007548:Isosorbide Dinitrate; D010100:Oxygen