Noninvasive ventilation in acute cardiogenic pulmonary edema.
BACKGROUND
Noninvasive ventilation (continuous positive airway pressure [CPAP] or noninvasive intermittent positive-pressure ventilation [NIPPV]) appears to be of benefit in the immediate treatment of patients with acute cardiogenic pulmonary edema and may reduce mortality. We conducted a study to determine whether noninvasive ventilation reduces mortality and whether there are important differences in outcome associated with the method of treatment (CPAP or NIPPV).


METHODS
In a multicenter, open, prospective, randomized, controlled trial, patients were assigned to standard oxygen therapy, CPAP (5 to 15 cm of water), or NIPPV (inspiratory pressure, 8 to 20 cm of water; expiratory pressure, 4 to 10 cm of water). The primary end point for the comparison between noninvasive ventilation and standard oxygen therapy was death within 7 days after the initiation of treatment, and the primary end point for the comparison between NIPPV and CPAP was death or intubation within 7 days.


RESULTS
A total of 1069 patients (mean [+/-SD] age, 77.7+/-9.7 years; female sex, 56.9%) were assigned to standard oxygen therapy (367 patients), CPAP (346 patients), or NIPPV (356 patients). There was no significant difference in 7-day mortality between patients receiving standard oxygen therapy (9.8%) and those undergoing noninvasive ventilation (9.5%, P=0.87). There was no significant difference in the combined end point of death or intubation within 7 days between the two groups of patients undergoing noninvasive ventilation (11.7% for CPAP and 11.1% for NIPPV, P=0.81). As compared with standard oxygen therapy, noninvasive ventilation was associated with greater mean improvements at 1 hour after the beginning of treatment in patient-reported dyspnea (treatment difference, 0.7 on a visual-analogue scale ranging from 1 to 10; 95% confidence interval [CI], 0.2 to 1.3; P=0.008), heart rate (treatment difference, 4 beats per minute; 95% CI, 1 to 6; P=0.004), acidosis (treatment difference, pH 0.03; 95% CI, 0.02 to 0.04; P<0.001), and hypercapnia (treatment difference, 0.7 kPa [5.2 mm Hg]; 95% CI, 0.4 to 0.9; P<0.001). There were no treatment-related adverse events.


CONCLUSIONS
In patients with acute cardiogenic pulmonary edema, noninvasive ventilation induces a more rapid improvement in respiratory distress and metabolic disturbance than does standard oxygen therapy but has no effect on short-term mortality. (Current Controlled Trials number, ISRCTN07448447.)
Gray
Alasdair
A
Royal Infirmary of Edinburgh, Edinburgh, United Kingdom. alasdair.gray@luht.scot.nhs.uk
Goodacre
Steve
S
Newby
David E
DE
Masson
Moyra
M
Sampson
Fiona
F
Nicholl
Jon
J
D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D045422:Continuous Positive Airway Pressure; D018450:Disease Progression; D005260:Female; D006331:Heart Diseases / Q000150:complications; D006801:Humans; D007385:Intermittent Positive-Pressure Ventilation / Q000379:methods; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D010102:Oxygen Inhalation Therapy; D011446:Prospective Studies; D011654:Pulmonary Edema / Q000209:etiology / Q000401:mortality / Q000628:therapy*