Chest
Volume 123, Issue 6, June 2003, Pages 2057-2061
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Clinical Investigations in Critical Care
Short-term Noninvasive Pressure Support Ventilation Prevents ICU Admittance in Patients With Acute Cardiogenic Pulmonary Edemaa

https://doi.org/10.1378/chest.123.6.2057Get rights and content

Study objectives

Noninvasive ventilation, although effective as treatment for patients with acute cardiogenic pulmonary edema when prolonged for hours, is of limited use in the emergency department (ED). The aim of the study was to determine whether a short attempt at noninvasive pressure support ventilation avoids ICU admittance and to identify lack of response prediction variables.

Design

Prospective inception cohort study.

Setting

ED of a university hospital.

Patients

Fifty-eight consecutive patients with cardiogenic pulmonary edema who had been unresponsive to medical treatment and were admitted between January 1999 and December 2000.

Interventions

Pressure support ventilation was instituted through a full-face mask until the resolution of respiratory failure. A 15-min “weaning test” was performed to evaluate clinical stability. Responder patients were transferred to a medical ward. Nonresponding patients were intubated and were admitted to the ICU.

Main outcome measures

The included optimal length of intervention, the avoidance of ICU admittance, the incidence of myocardial infarction, and predictive lack of response criteria.

Results

Patients completed the trial (mean [± SD] duration, 96 ± 40 min). None of the responders (43 patients; 74%) was subsequently ventilated or was admitted to the ICU. Two new episodes of myocardial infarction were observed. Thirteen of 58 patients died. A mean arterial pressure of < 95 mm Hg (odds ratio [OR], 10.6; 95% confidence interval [CI], 1.8 to 60.8; p < 0.01) and COPD (OR, 9.4; 95% CI, 1.6 to 54.0; p < 0.05) at baseline predicted the lack of response to noninvasive ventilation.

Conclusions

A short attempt at noninvasive ventilation is effective in preventing invasive assistance. A 15-min weaning test can identify patients who will not need further invasive ventilatory support. COPD and hypotension at baseline are negative predictive criteria.

Section snippets

Materials and Methods

The setting was the ED of a university hospital. This study was performed in accordance with the Declaration of Helsinki. Informed consent was given by the patients in the study or by their next of kin. All consecutive patients affected by ACPE who required respiratory assistance after the institution of conventional medical treatment (defined as therapy with morphine oxygen via face mask, diuretics, and vasoactive drugs) had proven to be ineffective were eligible for the study.

The inclusion

Results

Between January 1999 and December 2000, 58 consecutive patients with ACPE were enrolled in the study. The underlying diseases were as follows: ischemic heart disease (34 patients); COPD (16 patients); hypertension (15 patients); diabetes (7 patients); chronic renal failure (8 patients); and patent ductus (1 patient). Seven patients (12%) had signs of AMI at the time of hospital admission. Baseline hemodynamic and respiratory parameters, the data for which were collected before the onset of

Discussion

The great majority of patients with ACPE are initially managed in the ED. When patients do not respond to conventional medical treatment, ventilator assistance is needed. We tested the hypothesis that a short NIPSV run in the ED may avoid the use of invasive ventilation and admittance to the ICU. In the present study, critically ill patients were selected by their need for ventilatory support after undergoing ineffective conventional medical therapy for ACPE (eg, morphine, oxygen mask,

Acknowledgment

We thank Luca Bigatello for discussing our results, and Bruno Simini for his precious advice and suggestions in preparing and editing the manuscript.

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