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. 2005 Oct;81(960):637–643. doi: 10.1136/pgmj.2004.031229

Non-invasive ventilation in acute cardiogenic pulmonary oedema

R Agarwal 1, A Aggarwal 1, D Gupta 1, S Jindal 1
PMCID: PMC1743376  PMID: 16210459

Abstract

Non-invasive ventilation (NIV) is the delivery of assisted mechanical ventilation to the lungs, without the use of an invasive endotracheal airway. NIV has revolutionised the management of patients with various forms of respiratory failure. It has decreased the need for invasive mechanical ventilation and its attendant complications. Cardiogenic pulmonary oedema (CPO) is a common medical emergency, and NIV has been shown to improve both physiological and clinical outcomes. From the data presented herein, it is clear that there is sufficiently high level evidence to favour the use of continuous positive airway pressure (CPAP), and that the use of CPAP in patients with CPO decreases intubation rate and improves survival (number needed to treat seven and eight respectively). However, there is insufficient evidence to recommend the use of bilevel positive airway pressure (BiPAP), probably the exception being patients with hypercapnic CPO. More trials are required to conclusively define the role of BiPAP in CPO.

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Selected References

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  1. Aberman A., Fulop M. The metabolic and respiratory acidosis of acute pulmonary edema. Ann Intern Med. 1972 Feb;76(2):173–184. doi: 10.7326/0003-4819-76-2-173. [DOI] [PubMed] [Google Scholar]
  2. Antón Antonio, Tárrega Julia, Giner Jordi, Güell Rosa, Sanchis Joaquin. Acute physiologic effects of nasal and full-face masks during noninvasive positive-pressure ventilation in patients with acute exacerbations of chronic obstructive pulmonary disease. Respir Care. 2003 Oct;48(10):922–925. [PubMed] [Google Scholar]
  3. Appendini L., Patessio A., Zanaboni S., Carone M., Gukov B., Donner C. F., Rossi A. Physiologic effects of positive end-expiratory pressure and mask pressure support during exacerbations of chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1994 May;149(5):1069–1076. doi: 10.1164/ajrccm.149.5.8173743. [DOI] [PubMed] [Google Scholar]
  4. Atherton J. J., Moore T. D., Lele S. S., Thomson H. L., Galbraith A. J., Belenkie I., Tyberg J. V., Frenneaux M. P. Diastolic ventricular interaction in chronic heart failure. Lancet. 1997 Jun 14;349(9067):1720–1724. doi: 10.1016/S0140-6736(96)05109-4. [DOI] [PubMed] [Google Scholar]
  5. Aubier M., Trippenbach T., Roussos C. Respiratory muscle fatigue during cardiogenic shock. J Appl Physiol Respir Environ Exerc Physiol. 1981 Aug;51(2):499–508. doi: 10.1152/jappl.1981.51.2.499. [DOI] [PubMed] [Google Scholar]
  6. Baratz D. M., Westbrook P. R., Shah P. K., Mohsenifar Z. Effect of nasal continuous positive airway pressure on cardiac output and oxygen delivery in patients with congestive heart failure. Chest. 1992 Nov;102(5):1397–1401. doi: 10.1378/chest.102.5.1397. [DOI] [PubMed] [Google Scholar]
  7. Bellone Andrea, Monari Alessandra, Cortellaro Francesca, Vettorello Marco, Arlati Sergio, Coen Daniele. Myocardial infarction rate in acute pulmonary edema: noninvasive pressure support ventilation versus continuous positive airway pressure. Crit Care Med. 2004 Sep;32(9):1860–1865. doi: 10.1097/01.ccm.0000139694.47326.b6. [DOI] [PubMed] [Google Scholar]
  8. Bersten A. D., Holt A. W., Vedig A. E., Skowronski G. A., Baggoley C. J. Treatment of severe cardiogenic pulmonary edema with continuous positive airway pressure delivered by face mask. N Engl J Med. 1991 Dec 26;325(26):1825–1830. doi: 10.1056/NEJM199112263252601. [DOI] [PubMed] [Google Scholar]
  9. Bersten Andrew D. Noninvasive ventilation for cardiogenic pulmonary edema: froth and bubbles? Am J Respir Crit Care Med. 2003 Dec 15;168(12):1406–1408. doi: 10.1164/rccm.2309016. [DOI] [PubMed] [Google Scholar]
  10. Bradley T. D., Holloway R. M., McLaughlin P. R., Ross B. L., Walters J., Liu P. P. Cardiac output response to continuous positive airway pressure in congestive heart failure. Am Rev Respir Dis. 1992 Feb;145(2 Pt 1):377–382. doi: 10.1164/ajrccm/145.2_Pt_1.377. [DOI] [PubMed] [Google Scholar]
  11. Brochard L., Mancebo J., Elliott M. W. Noninvasive ventilation for acute respiratory failure. Eur Respir J. 2002 Apr;19(4):712–721. doi: 10.1183/09031936.02.00295502. [DOI] [PubMed] [Google Scholar]
  12. Brochard Laurent. Noninvasive ventilation for acute respiratory failure. JAMA. 2002 Aug 28;288(8):932–935. doi: 10.1001/jama.288.8.932. [DOI] [PubMed] [Google Scholar]
  13. Broseghini C., Brandolese R., Poggi R., Polese G., Manzin E., Milic-Emili J., Rossi A. Respiratory mechanics during the first day of mechanical ventilation in patients with pulmonary edema and chronic airway obstruction. Am Rev Respir Dis. 1988 Aug;138(2):355–361. doi: 10.1164/ajrccm/138.2.355. [DOI] [PubMed] [Google Scholar]
  14. Buda A. J., Pinsky M. R., Ingels N. B., Jr, Daughters G. T., 2nd, Stinson E. B., Alderman E. L. Effect of intrathoracic pressure on left ventricular performance. N Engl J Med. 1979 Aug 30;301(9):453–459. doi: 10.1056/NEJM197908303010901. [DOI] [PubMed] [Google Scholar]
  15. Chadda Karim, Annane Djillali, Hart Nicholas, Gajdos Philippe, Raphaël Jean Claude, Lofaso Frédéric. Cardiac and respiratory effects of continuous positive airway pressure and noninvasive ventilation in acute cardiac pulmonary edema. Crit Care Med. 2002 Nov;30(11):2457–2461. doi: 10.1097/00003246-200211000-00009. [DOI] [PubMed] [Google Scholar]
  16. Cotter G., Metzkor E., Kaluski E., Faigenberg Z., Miller R., Simovitz A., Shaham O., Marghitay D., Koren M., Blatt A. Randomised trial of high-dose isosorbide dinitrate plus low-dose furosemide versus high-dose furosemide plus low-dose isosorbide dinitrate in severe pulmonary oedema. Lancet. 1998 Feb 7;351(9100):389–393. doi: 10.1016/S0140-6736(97)08417-1. [DOI] [PubMed] [Google Scholar]
  17. Cotter Gad, Moshkovitz Yaron, Milovanov Olga, Salah Ahmed, Blatt Alex, Krakover Ricardo, Vered Zvi, Kaluski Edo. Acute heart failure: a novel approach to its pathogenesis and treatment. Eur J Heart Fail. 2002 Jun;4(3):227–234. doi: 10.1016/s1388-9842(02)00017-x. [DOI] [PubMed] [Google Scholar]
  18. Crane S. D., Elliott M. W., Gilligan P., Richards K., Gray A. J. Randomised controlled comparison of continuous positive airways pressure, bilevel non-invasive ventilation, and standard treatment in emergency department patients with acute cardiogenic pulmonary oedema. Emerg Med J. 2004 Mar;21(2):155–161. doi: 10.1136/emj.2003.005413. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Ferguson G. T., Gilmartin M. CO2 rebreathing during BiPAP ventilatory assistance. Am J Respir Crit Care Med. 1995 Apr;151(4):1126–1135. doi: 10.1164/ajrccm/151.4.1126. [DOI] [PubMed] [Google Scholar]
  20. Fessler H. E., Brower R. G., Wise R. A., Permutt S. Effects of systolic and diastolic positive pleural pressure pulses with altered cardiac contractility. J Appl Physiol (1985) 1992 Aug;73(2):498–505. doi: 10.1152/jappl.1992.73.2.498. [DOI] [PubMed] [Google Scholar]
  21. Fessler H. E., Brower R. G., Wise R. A., Permutt S. Mechanism of reduced LV afterload by systolic and diastolic positive pleural pressure. J Appl Physiol (1985) 1988 Sep;65(3):1244–1250. doi: 10.1152/jappl.1988.65.3.1244. [DOI] [PubMed] [Google Scholar]
  22. Field S., Kelly S. M., Macklem P. T. The oxygen cost of breathing in patients with cardiorespiratory disease. Am Rev Respir Dis. 1982 Jul;126(1):9–13. doi: 10.1164/arrd.1982.126.1.9. [DOI] [PubMed] [Google Scholar]
  23. Gehlbach Brian K., Geppert Eugene. The pulmonary manifestations of left heart failure. Chest. 2004 Feb;125(2):669–682. doi: 10.1378/chest.125.2.669. [DOI] [PubMed] [Google Scholar]
  24. Hess Dean R. The evidence for noninvasive positive-pressure ventilation in the care of patients in acute respiratory failure: a systematic review of the literature. Respir Care. 2004 Jul;49(7):810–829. [PubMed] [Google Scholar]
  25. Katz J. A., Kraemer R. W., Gjerde G. E. Inspiratory work and airway pressure with continuous positive airway pressure delivery systems. Chest. 1985 Oct;88(4):519–526. doi: 10.1378/chest.88.4.519. [DOI] [PubMed] [Google Scholar]
  26. Kelly C. A., Newby D. E., McDonagh T. A., Mackay T. W., Barr J., Boon N. A., Dargie H. J., Douglas N. J. Randomised controlled trial of continuous positive airway pressure and standard oxygen therapy in acute pulmonary oedema; effects on plasma brain natriuretic peptide concentrations. Eur Heart J. 2002 Sep;23(17):1379–1386. doi: 10.1053/euhj.2001.3156. [DOI] [PubMed] [Google Scholar]
  27. Kwok Henry, McCormack James, Cece Richard, Houtchens Jeanne, Hill Nicholas S. Controlled trial of oronasal versus nasal mask ventilation in the treatment of acute respiratory failure. Crit Care Med. 2003 Feb;31(2):468–473. doi: 10.1097/01.CCM.0000045563.64187.20. [DOI] [PubMed] [Google Scholar]
  28. L'Her Erwan, Duquesne Françoise, Girou Emmanuelle, de Rosiere Xavier Donin, Le Conte Philippe, Renault Serge, Allamy Jean-Paul, Boles Jean-Michel. Noninvasive continuous positive airway pressure in elderly cardiogenic pulmonary edema patients. Intensive Care Med. 2004 Feb 28;30(5):882–888. doi: 10.1007/s00134-004-2183-y. [DOI] [PubMed] [Google Scholar]
  29. Lapinsky S. E., Mount D. B., Mackey D., Grossman R. F. Management of acute respiratory failure due to pulmonary edema with nasal positive pressure support. Chest. 1994 Jan;105(1):229–231. doi: 10.1378/chest.105.1.229. [DOI] [PubMed] [Google Scholar]
  30. Lenique F., Habis M., Lofaso F., Dubois-Randé J. L., Harf A., Brochard L. Ventilatory and hemodynamic effects of continuous positive airway pressure in left heart failure. Am J Respir Crit Care Med. 1997 Feb;155(2):500–505. doi: 10.1164/ajrccm.155.2.9032185. [DOI] [PubMed] [Google Scholar]
  31. Levitt M. A. A prospective, randomized trial of BiPAP in severe acute congestive heart failure. J Emerg Med. 2001 Nov;21(4):363–369. doi: 10.1016/s0736-4679(01)00385-7. [DOI] [PubMed] [Google Scholar]
  32. Lin M., Chiang H. T. The efficacy of early continuous positive airway pressure therapy in patients with acute cardiogenic pulmonary edema. J Formos Med Assoc. 1991 Aug;90(8):736–743. [PubMed] [Google Scholar]
  33. Lin M., Yang Y. F., Chiang H. T., Chang M. S., Chiang B. N., Cheitlin M. D. Reappraisal of continuous positive airway pressure therapy in acute cardiogenic pulmonary edema. Short-term results and long-term follow-up. Chest. 1995 May;107(5):1379–1386. doi: 10.1378/chest.107.5.1379. [DOI] [PubMed] [Google Scholar]
  34. Lofaso F., Brochard L., Hang T., Lorino H., Harf A., Isabey D. Home versus intensive care pressure support devices. Experimental and clinical comparison. Am J Respir Crit Care Med. 1996 May;153(5):1591–1599. doi: 10.1164/ajrccm.153.5.8630607. [DOI] [PubMed] [Google Scholar]
  35. Masip J., Betbesé A. J., Páez J., Vecilla F., Cañizares R., Padró J., Paz M. A., de Otero J., Ballús J. Non-invasive pressure support ventilation versus conventional oxygen therapy in acute cardiogenic pulmonary oedema: a randomised trial. Lancet. 2000 Dec 23;356(9248):2126–2132. doi: 10.1016/s0140-6736(00)03492-9. [DOI] [PubMed] [Google Scholar]
  36. Masip Josep, Páez Joaquim, Merino Montserrat, Parejo Sandra, Vecilla Francisco, Riera Clara, Ríos Araceli, Sabater Joan, Ballús Josep, Padró J. Risk factors for intubation as a guide for noninvasive ventilation in patients with severe acute cardiogenic pulmonary edema. Intensive Care Med. 2003 Sep 10;29(11):1921–1928. doi: 10.1007/s00134-003-1922-9. [DOI] [PubMed] [Google Scholar]
  37. Mehta S., Hill N. S. Noninvasive ventilation. Am J Respir Crit Care Med. 2001 Feb;163(2):540–577. doi: 10.1164/ajrccm.163.2.9906116. [DOI] [PubMed] [Google Scholar]
  38. Mehta S., Jay G. D., Woolard R. H., Hipona R. A., Connolly E. M., Cimini D. M., Drinkwine J. H., Hill N. S. Randomized, prospective trial of bilevel versus continuous positive airway pressure in acute pulmonary edema. Crit Care Med. 1997 Apr;25(4):620–628. doi: 10.1097/00003246-199704000-00011. [DOI] [PubMed] [Google Scholar]
  39. Naughton M. T., Rahman M. A., Hara K., Floras J. S., Bradley T. D. Effect of continuous positive airway pressure on intrathoracic and left ventricular transmural pressures in patients with congestive heart failure. Circulation. 1995 Mar 15;91(6):1725–1731. doi: 10.1161/01.cir.91.6.1725. [DOI] [PubMed] [Google Scholar]
  40. Nava S., Ambrosino N., Rubini F., Fracchia C., Rampulla C., Torri G., Calderini E. Effect of nasal pressure support ventilation and external PEEP on diaphragmatic activity in patients with severe stable COPD. Chest. 1993 Jan;103(1):143–150. doi: 10.1378/chest.103.1.143. [DOI] [PubMed] [Google Scholar]
  41. Nava Stefano, Carbone Giorgio, DiBattista Nicola, Bellone Andrea, Baiardi Paola, Cosentini Roberto, Marenco Mauro, Giostra Fabrizio, Borasi Guido, Groff Paolo. Noninvasive ventilation in cardiogenic pulmonary edema: a multicenter randomized trial. Am J Respir Crit Care Med. 2003 Sep 4;168(12):1432–1437. doi: 10.1164/rccm.200211-1270OC. [DOI] [PubMed] [Google Scholar]
  42. Navalesi P., Fanfulla F., Frigerio P., Gregoretti C., Nava S. Physiologic evaluation of noninvasive mechanical ventilation delivered with three types of masks in patients with chronic hypercapnic respiratory failure. Crit Care Med. 2000 Jun;28(6):1785–1790. doi: 10.1097/00003246-200006000-00015. [DOI] [PubMed] [Google Scholar]
  43. Noble W. H., Kay J. C., Obdrzalek J. Lung mechanics in hypervolemic pulmonary edema. J Appl Physiol. 1975 Apr;38(4):681–687. doi: 10.1152/jappl.1975.38.4.681. [DOI] [PubMed] [Google Scholar]
  44. Pang D., Keenan S. P., Cook D. J., Sibbald W. J. The effect of positive pressure airway support on mortality and the need for intubation in cardiogenic pulmonary edema: a systematic review. Chest. 1998 Oct;114(4):1185–1192. doi: 10.1378/chest.114.4.1185. [DOI] [PubMed] [Google Scholar]
  45. Park M., Lorenzi-Filho G., Feltrim M. I., Viecili P. R., Sangean M. C., Volpe M., Leite P. F., Mansur A. J. Oxygen therapy, continuous positive airway pressure, or noninvasive bilevel positive pressure ventilation in the treatment of acute cardiogenic pulmonary edema. Arq Bras Cardiol. 2001 Mar;76(3):221–230. doi: 10.1590/s0066-782x2001000300005. [DOI] [PubMed] [Google Scholar]
  46. Park Marcelo, Sangean Marcia C., Volpe Marcia de S., Feltrim Maria I. Z., Nozawa Emilia, Leite Paulo F., Passos Amato Marcelo B., Lorenzi-Filho Geraldo. Randomized, prospective trial of oxygen, continuous positive airway pressure, and bilevel positive airway pressure by face mask in acute cardiogenic pulmonary edema. Crit Care Med. 2004 Dec;32(12):2407–2415. doi: 10.1097/01.ccm.0000147770.20400.10. [DOI] [PubMed] [Google Scholar]
  47. Perel A., Williamson D. C., Modell J. H. Effectiveness of CPAP by mask for pulmonary edema associated with hypercarbia. Intensive Care Med. 1983;9(1):17–19. doi: 10.1007/BF01693700. [DOI] [PubMed] [Google Scholar]
  48. Poponick J. M., Renston J. P., Bennett R. P., Emerman C. L. Use of a ventilatory support system (BiPAP) for acute respiratory failure in the emergency department. Chest. 1999 Jul;116(1):166–171. doi: 10.1378/chest.116.1.166. [DOI] [PubMed] [Google Scholar]
  49. Poppas Athena, Rounds Sharon. Congestive heart failure. Am J Respir Crit Care Med. 2002 Jan 1;165(1):4–8. doi: 10.1164/ajrccm.165.1.2102075. [DOI] [PubMed] [Google Scholar]
  50. Richards G. N., Cistulli P. A., Ungar R. G., Berthon-Jones M., Sullivan C. E. Mouth leak with nasal continuous positive airway pressure increases nasal airway resistance. Am J Respir Crit Care Med. 1996 Jul;154(1):182–186. doi: 10.1164/ajrccm.154.1.8680678. [DOI] [PubMed] [Google Scholar]
  51. Rusterholtz T., Kempf J., Berton C., Gayol S., Tournoud C., Zaehringer M., Jaeger A., Sauder P. Noninvasive pressure support ventilation (NIPSV) with face mask in patients with acute cardiogenic pulmonary edema (ACPE) Intensive Care Med. 1999 Jan;25(1):21–28. doi: 10.1007/s001340050782. [DOI] [PubMed] [Google Scholar]
  52. Räsänen J., Heikkilä J., Downs J., Nikki P., Väisänen I., Viitanen A. Continuous positive airway pressure by face mask in acute cardiogenic pulmonary edema. Am J Cardiol. 1985 Feb 1;55(4):296–300. doi: 10.1016/0002-9149(85)90364-9. [DOI] [PubMed] [Google Scholar]
  53. SHARP J. T., GRIFFITH G. T., BUNNELL I. L., GREENE D. G. Ventilatory mechanics in pulmonary edema in man. J Clin Invest. 1958 Jan;37(1):111–117. doi: 10.1172/JCI103577. [DOI] [PMC free article] [PubMed] [Google Scholar]
  54. Saatci E., Miller D. M., Stell I. M., Lee K. C., Moxham J. Dynamic dead space in face masks used with noninvasive ventilators: a lung model study. Eur Respir J. 2004 Jan;23(1):129–135. doi: 10.1183/09031936.03.00039503. [DOI] [PubMed] [Google Scholar]
  55. Schwartz Andrew R., Kacmarek Robert M., Hess Dean R. Factors affecting oxygen delivery with bi-level positive airway pressure. Respir Care. 2004 Mar;49(3):270–275. [PubMed] [Google Scholar]
  56. Seals D. R., Suwarno N. O., Dempsey J. A. Influence of lung volume on sympathetic nerve discharge in normal humans. Circ Res. 1990 Jul;67(1):130–141. doi: 10.1161/01.res.67.1.130. [DOI] [PubMed] [Google Scholar]
  57. Sharon A., Shpirer I., Kaluski E., Moshkovitz Y., Milovanov O., Polak R., Blatt A., Simovitz A., Shaham O., Faigenberg Z. High-dose intravenous isosorbide-dinitrate is safer and better than Bi-PAP ventilation combined with conventional treatment for severe pulmonary edema. J Am Coll Cardiol. 2000 Sep;36(3):832–837. doi: 10.1016/s0735-1097(00)00785-3. [DOI] [PubMed] [Google Scholar]
  58. Takeda S., Nejima J., Takano T., Nakanishi K., Takayama M., Sakamoto A., Ogawa R. Effect of nasal continuous positive airway pressure on pulmonary edema complicating acute myocardial infarction. Jpn Circ J. 1998 Aug;62(8):553–558. doi: 10.1253/jcj.62.553. [DOI] [PubMed] [Google Scholar]
  59. Valipour Arschang, Cozzarini Wolfgang, Burghuber Otto C. Non-invasive pressure support ventilation in patients with respiratory failure due to severe acute cardiogenic pulmonary edema. Respiration. 2004 Mar-Apr;71(2):144–151. doi: 10.1159/000076675. [DOI] [PubMed] [Google Scholar]
  60. Viale J. P., Annat G. J., Bouffard Y. M., Delafosse B. X., Bertrand O. M., Motin J. P. Oxygen cost of breathing in postoperative patients. Pressure support ventilation vs continuous positive airway pressure. Chest. 1988 Mar;93(3):506–509. doi: 10.1378/chest.93.3.506. [DOI] [PubMed] [Google Scholar]
  61. Väisänen I. T., Räsänen J. Continuous positive airway pressure and supplemental oxygen in the treatment of cardiogenic pulmonary edema. Chest. 1987 Sep;92(3):481–485. doi: 10.1378/chest.92.3.481. [DOI] [PubMed] [Google Scholar]

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