Non invasive ventilation for cardiogenic pulmunary edema in ICCU: froth and bubbles

Background. Respiratory failure associated with acute cardiogenic pulmonary edema (ACPE) characterizes an important subgroup of patients with treatment difficulties. These patients when receiving noninvasive positive pressure ventilation (NPPV) via helmet, experienced more effective output with respect to the single therapy. Objectives. To evaluate the clinical application of NPPV in ACPE complicated by respiratory effort (RE) hospitalized in ICCU. Population. From January to June 2010, 28 ACPE complicated by RE have been treated with medical therapy and NPPV via helmet. RE is defined by a D-pCO2 >2 mmHg value at the entry. D-pCO2 is the difference between pCO2 measured and awaited (pCO2 awaited = 1.5*HCO3+8). Intervention. The helmet is made of transparent latex-free PVC. The helmet is secured by two armpit breces at two hooks on the metallic ring that joins the helmet with a soft collar. The pressure increase during ventilation makes the soft collar seal comfortably to the neck and the shoulders, avoiding air leakage. The two ports of the helmet act as inlet and outlet of the gas flow. the inspiratory and expiratory valves are those of mechanical ventilator. Patients with cardiogenic shock, chronic respiratory failure (CRF), anaemia, and other not cardiac causes of dyspnea have been excluded. Initial ventilatory settings were continuous positive airway pressure (CPAP) mode, 5 cm H2O, with pressure support ventilation of 10 to 20 cm H2O titrated to achieve a respiratory rate less than 25 breaths/min and an exhaled tidal volume of 7 mL/kg or more. Ventilator settings were adjusted following arterial blood gases (ABG) results. Results. Failure to improve ABG values was the reason for ETI in 2 patients (7%). One patient has died during treatment (3.5%). two patients did not tolerate the helmet (7%). No complications developed for the use of the helmet.The average duration of NPPV was 27±12 h. After 12 hours of the NINV in these patients has determined an improvement of the cardiac frequency from 109±16 to 81±12 (p=0.002), respiratory frequency from 38±6 to 19±3 (p=0.002). Arterial blood saturation increased from 74%±14 to 96%±5 (p<0.0001), pH from 7.21±0.10 to 7.40±0.09 (p=0.001), pO2 from 52±16 to 100±31 (p<0.001) as well, while pCO2 decreased from 66±17 to 41±10 (p=0.02).Significant variations of systolic and diastolic blood pressure where not reported. 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, has no effect on short-term mortality. The application of NPPV in clinical practice in ICCU is a cardiologist’s effective and safe alternative to ETI for a patients affected by respiratory failure associated with ACPE. 158S G