Continuous positive airway pressure versus bilevel noninvasive ventilation in acute cardiogenic pulmonary edema: a randomized multicenter trial.
OBJECTIVE
Patients with acute cardiogenic pulmonary edema may develop respiratory failure. Noninvasive respiratory support should be initiated rapidly to avoid tracheal intubation. The aim of this study is to compare the efficacy of continuous positive airway pressure (CPAP) delivered by the Boussignac CPAP device and bilevel positive airway pressure (bilevel PAP) in patients with acute respiratory failure caused by acute cardiogenic pulmonary edema.


METHODS
This prospective multicenter randomized study was conducted in 3 emergency departments. Patients were assigned to Boussignac CPAP through a facemask or to bilevel PAP, in addition to standard therapy. The main outcome was a combined criterion (tracheal intubation, death, or acute myocardial infarction). Complications, durations of ventilation, and hospitalization were also assessed.


RESULTS
After 1 hour of ventilation and at the end of the ventilation period, clinical parameters of respiratory distress and blood gas exchange significantly improved in each treatment arm. No significant differences were observed between the Boussignac CPAP and bilevel PAP arms for the combined criterion (5% versus 12%, respectively; odds ratio [OR] 0.4; 95% confidence interval [CI] 0.0 to 1.9) and also for severe complications (9% versus 6%; OR 1.5; 95% CI 0.3 to 9.9), duration of ventilation (median for both groups 2 hours; interquartile range [IQR] 1.2 to 3.0 hours), duration of hospitalization (CPAP 8.5 [IQR 6 to 14] days; bilevel PAP 10 [IQR 7 to 16] days), or intrahospital mortality (8% versus 14%; OR 1.8 [IQR 0.4 to 8.8]). Similar results were obtained among hypercapnic patients (PaCO2 >45 mm Hg). Whatever the ventilation support used, the combined criterion and severe complications were more frequently observed among hypercapnic patients.


CONCLUSIONS
Both Boussignac CPAP and bilevel PAP appeared effective in rapidly improving respiratory distress even in hypercapnic patients, but they were not different in terms of patient outcome.
Moritz
Fabienne
F
Service d'Accueil et d'Urgences, CHU de Rouen, Hôpital Charles Nicolle, University Hospital, Rouen, France. Fabienne.Moritz@chu-rouen.fr
Brousse
Benoit
B
Gellée
Bruno
B
Chajara
Abdesslam
A
L'Her
Erwan
E
Hellot
Marie-France
MF
Bénichou
Jacques
J
D000208:Acute Disease; D000368:Aged; D045422:Continuous Positive Airway Pressure / Q000295:instrumentation / Q000379:methods*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D005260:Female; D005602:France / Q000453:epidemiology; D017052:Hospital Mortality; D006801:Humans; D017214:Laryngeal Masks; D007902:Length of Stay; D008297:Male; D011446:Prospective Studies; D011654:Pulmonary Edema / Q000401:mortality / Q000628:therapy*; D016896:Treatment Outcome