Noninvasive ventilation in acute cardiogenic pulmonary edema
Alasdair Gray, Steve Goodacre, David E Newby, Moyra Masson, Fiona Sampson, Jon Nicholl, 3CPO Trialists, A Gray, D Newby, C Kelly, N Douglas, M Masson, S Goodacre, J Nicholl, F Sampson, K Paulucy, Y Oluboyede, K Stevens, S Crane, M Elliott, P Plant, T Hassan, Y Meades, A Saunderson, E Mowat, V Lawler, E Gendall, H Purvis, E Norwood, T Woodrow, Z Gall, C Roberts, D Mill, J Groves, J Gilks, G Symmons, Y Whattam, T Coats, R Davies, M Elliott, S Goodacre, A Gray, D Newby, M Masson, T McDonagh, P Hall, R Prescott, A Hargreaves, C Selby, U MacIntosh, A Gray, P Munro, N Nichol, C McGuffie, J Keaney, S Goodacre, S Crane, S Bush, T Hassan, J Brenchley, H Law, M Shepherd, J Kendall, D Williamson, J Benger, G Lloyd, S Cope, C Gavin, J Butler, F Andrews, D Walter, M Higgins, A Bleetman, P Doyle, P Dissmann, I Stell, Alasdair Gray, Steve Goodacre, David E Newby, Moyra Masson, Fiona Sampson, Jon Nicholl, 3CPO Trialists, A Gray, D Newby, C Kelly, N Douglas, M Masson, S Goodacre, J Nicholl, F Sampson, K Paulucy, Y Oluboyede, K Stevens, S Crane, M Elliott, P Plant, T Hassan, Y Meades, A Saunderson, E Mowat, V Lawler, E Gendall, H Purvis, E Norwood, T Woodrow, Z Gall, C Roberts, D Mill, J Groves, J Gilks, G Symmons, Y Whattam, T Coats, R Davies, M Elliott, S Goodacre, A Gray, D Newby, M Masson, T McDonagh, P Hall, R Prescott, A Hargreaves, C Selby, U MacIntosh, A Gray, P Munro, N Nichol, C McGuffie, J Keaney, S Goodacre, S Crane, S Bush, T Hassan, J Brenchley, H Law, M Shepherd, J Kendall, D Williamson, J Benger, G Lloyd, S Cope, C Gavin, J Butler, F Andrews, D Walter, M Higgins, A Bleetman, P Doyle, P Dissmann, I Stell
Abstract
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.)
2008 Massachusetts Medical Society
Source: PubMed