Noninvasive Ventilation in Acute Cardiogenic Pulmonary Edema Alasdair Gray, M.D., Steve Goodacre, Ph.D., David E. Newby, M.D., Moyra Masson, M.Sc., Fiona Sampson, M.Sc., and Jon Nicholl, M.Sc., for the 3CPO Trialists N Engl J Med 2008;359: Presented by Cho, Chang-hyun Original article

Background ► Noninvasive ventilation  continuous positive airway pressure ; CPAP ( 5 to 15 cm of water)  noninvasive intermittent positive-pressure ventilation ; NIPPV ( inspiratory pressure, 8 to 20 cm of water; expiratory pressure, 4 to 10 cm of water)

► Likely benefit in immediate Tx of Pts with acute cardiogenic pulmonary edema & reduce mortality  Oxygenation ↑  Work of Breathing ↓  Cardiac output ↑ ► Prev. Studies ; small & single center  ? noninvasive ventilation reduces mortality  ? differences in CPAP or NIPPV  multicenter, open, prospective, randomized, controlled trial

Methods ► In a multicenter, open, prospective, randomized, controlled trial ► In UK, July 2003 ~ April 2007  standard oxygen therapy ( O2 15 L/min with reservior )  CPAP ( 5 to 15 cm of water)  NIPPV ( inspiratory pressure, 8 to 20 cm of water; expiratory pressure, 4 to 10 cm of water)

► The inclusion criteria  age of more than 16 years  clinical diagnosis of acute cardiogenic pulmonary edema  pulmonary edema shown by a chest radiograph  respiratory rate of more than 20 breaths per minute  ABGA ; pH <7.35 ► The exclusion criteria  Requirement for a lifesaving or emergency intervention  inability to give consent  previous recruitment into the trial

► Primary end point for the comparison between noninvasive ventilation and standard oxygen therapy  death within 7 days ► Primary end point for the comparison between NIPPV and CPAP  death or intubation within 7 days ► Secondary end points  dyspnea, physiological variables, intubation within 7 days, length of hospital stay, admission to the critical care unit, and death within 30 days.  dyspnea, physiological variables, intubation within 7 days, length of hospital stay, admission to the critical care unit, and death within 30 days.

Results

Table 1. Baseline Characteristics of the Patients ( Total = 1069 Pts )

Table 2. Treatment of Patients

Figure 1. Kaplan.Meier Survival Curves ( Primary outcomes)

Table 3. End Points for Pts Receiving Standard Oxygen Tx & Noninvasive Ventilation

Table 4. End Points for Pts Receiving CPAP and Those Receiving NIPPV

Conclusions ► In 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