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Randomized, prospective trial of bilevel versus continuous positive airway pressure in acute pulmonary edema

Mehta, Sangeeta MD; Jay, Gregory D. MD, PhD; Woolard, Robert H. MD, FACEP; Hipona, Rene A. MD; Connolly, Emily M. RN; Cimini, Donna M. RN; Drinkwine, Joseph H. RRT; Hill, Nicholas S. MD, FCCP

Clinical Investigation

Objective  To evaluate whether bilevel positive airway pressure, by actively assisting inhalation, more rapidly improves ventilation, acidemia, and dyspnea than continuous positive airway pressure (CPAP) in patients with acute pulmonary edema.

Design  Randomized, controlled, double-blind trial.

Setting  Emergency department in a university hospital.

Patients  Twenty-seven patients, presenting with acute pulmonary edema, characterized by dyspnea, tachypnea, tachycardia, accessory muscle use, bilateral rales, and typical findings of congestion on a chest radiograph.

Interventions  In addition to standard therapy, 13 patients were randomized to receive nasal CPAP (10 cm H2 O), and 14 patients were randomized to receive nasal bilevel positive airway pressure (inspiratory and expiratory positive airway pressures of 15 and 5 cm H2 O, respectively) in the spontaneous/timed mode that combines patient flow-triggering and backup time-triggering.

Measurements and Main Results  After 30 mins, significant reductions in breathing frequency (32 +/- 4 to 26 +/- 5 breaths/min), heart rate (110 +/- 21 to 97 +/- 20 beats/min), blood pressure (mean 117 +/- 28 to 92 +/- 18 mm Hg), and PaCO2 (56 +/- 15 to 43 +/- 9 torr [7.5 +/- 2 to 5.7 +/- 1.2 kPa]) were observed in the bilevel positive airway pressure group, as were significant improvements in arterial pH and dyspnea scores (p < .05 for all of these parameters). Only breathing frequency improved significantly in the CPAP group (32 +/- 4 to 28 +/- 5 breaths/min, p < .05). At 30 mins, the bilevel positive airway pressure group had greater reductions in PaCO2 (p = .057), systolic blood pressure (p = .005), and mean arterial pressure (p = .03) than the CPAP group. The myocardial infarction rate was higher in the bilevel positive airway pressure group (71%) compared with both the CPAP group (31%) and historically matched controls (38%) (p = .05). Duration of ventilator use, intensive care unit and hospital stays, and intubation and mortality rates were similar between the two groups.

Conclusions  Bilevel positive airway pressure improves ventilation and vital signs more rapidly than CPAP in patients with acute pulmonary edema. The higher rate of myocardial infarctions associated with the use of bilevel positive airway pressure highlights the need for further studies to clarify its effects on hemodynamics and infarction rates, and to determine optimal pressure settings. (Crit Care Med 1997; 25:620-628)

From the Divisions of Pulmonary, Critical Care, and Emergency Medicine, Rhode Island Hospital and Brown University School of Medicine, Providence, RI.

Supported, in part, by Respironics, Murrysville, PA.

Address requests for reprints to: Nicholas S. Hill, MD, Pulmonary and Critical Care Medicine, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903.

© Williams & Wilkins 1997. All Rights Reserved.