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CPAP for acute cardiogenic pulmonary oedema from out-of-hospital to cardiac intensive care unit: a randomised multicentre study

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Abstract

Purpose

Continuous positive airway pressure (CPAP) is a useful treatment for patients with acute cardiogenic pulmonary oedema (CPE). However, its usefulness in the out-of-hospital setting has been poorly investigated and only by small and single-centre studies. We designed a multicentre randomised study to assess the benefit of CPAP initiated out of hospital.

Methods

A total of 207 patients with CPE were randomly allocated by emergency mobile medical units to receive either standard treatment alone or standard treatment plus CPAP. CPAP was maintained after admission to the intensive care unit (ICU). Inclusion criteria were orthopnoea, respiratory rate greater than 25 breaths/min, pulse oximetry less than 90% in room air and diffuse crackles. The primary end point was assessed during the first 48 h and combined: death, presence of intubation criteria, persistence of either all inclusion criteria or circulatory failure at the second hour or their reappearance before 48 h. Absence of all criteria defined successful treatment.

Results

CPAP was used for 60 min [40, 65] (median [Q1, Q3]) in the pre-hospital setting and 120 min [60, 242] in ICU and was well tolerated in all patients. Treatment was successful in 79% of patients in the CPAP group and 63% in the control group (p = 0.01), especially for persistence of inclusion criteria after 2 h (12 vs. 26%) and for intubation criteria (4 vs. 14%). CPAP was beneficial irrespective of the initial PaCO2 or left ventricular ejection fraction.

Conclusion

Immediate use of CPAP in out-of-hospital treatment of CPE and until CPE resolves after admission significantly improves early outcome compared with medical treatment alone.

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Acknowledgments

The French Ministry of Health provided financial support (2004 Clinical Research Hospital Program PHRC 2004 NCT 00554580). We thank Denise Mockers, Laurence Guéry and Véronique Jouis, as members of the Clinical Research Unit for the data safety and monitoring; Valerie Scarceriaux, Eric Brottier and the Gamida company for their help in initiating the study; and Alexandre Mebazaa for reviewing this report. The BNP assay and CPAP mask were gifts from Biosite company and Respironics Philips, respectively, through an agreement between the French Heath Ministry and the companies. In memory of Christine Berton who helped design the study at the beginning of the project.

Conflict of interest

Laurent Ducros conducted NIV training sessions funded by Respironics Philips France.

Author information

Authors and Affiliations

  1. Département d’Anesthésie-Réanimation-SMUR, Hôpital Universitaire Lariboisière, AP-HP, 2, rue Ambroise Paré, 75010, Paris, France

    Laurent Ducros, Claire Broche, Papa Gueye & Didier Payen

  2. Service de Cardiologie, Hôpital Universitaire Lariboisière, AP-HP, Paris, France

    Damien Logeart, Patrick Henry & Jean-Michel Tartière

  3. Unité de Recherche Clinique, Hôpital Universitaire Lariboisière, AP-HP, Paris, France

    Eric Vicaut

  4. Service des Urgences, Hôpital Universitaire Lariboisière, AP-HP, Paris, France

    Patrick Plaisance

  5. Institut de Cardiologie, Groupe Hospitalier Universitaire Pitié-Salpétrière, AP-HP, Paris, France

    Jean-Philippe Collet & Gilles Montalescot

  6. SAMU 29, Centre Hospitalier Universitaire La Cavale Blanche, Brest, France

    Muriel Vergne

  7. Service des Urgences, Centre Hospitalier Universitaire La Cavale Blanche, Brest, France

    David Goetgheber

  8. Service de Cardiologie, Centre Hospitalier Universitaire La Cavale Blanche, Brest, France

    Pierre-Yves Pennec

  9. Département d’Anesthésie-Réanimation-SMUR, Groupe Hospitalier Pitié-Salpétrière, AP-HP, Paris, France

    Marie-Laurence Fievet

  10. Département d’Anesthésie-Réanimation-SMUR, Hôpital Beaujon, AP-HP, Clichy, France

    Vanessa Belpomme

  11. SAMU 45, Centre Hospitalier Régional d’Orléans, La Source Orléans, France

    Sophie Lagarde

  12. Service de Cardiologie, Clinique La Reine Blanche, Orléans, France

    Marius Placente

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  1. Laurent Ducros
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on behalf of the CPAP collaborative study group

Corresponding author

Correspondence to Laurent Ducros.

Additional information

CPAP collaborative study group members are given in the Appendix.

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CPAP collaborative study group members

CPAP collaborative study group members

Daniel Jannière, MD (SAMU 75, Hôpital Necker, AP-HP, Paris, France), Christophe Bensouda, MD (Service de Cardiologie, Hôpital Européen Georges Pompidou, AP-HP, Paris, France), Frédérique Charles, MD (Services des Urgences-SMUR, Centre Hospitalier de Béziers, France), Mohamed Elsayed, MD (SMUR, Hôpital Simone Veil Groupe Hospitalier Eaubonne-Montmorency, France), Nachwam Ghanem, MD (Service de Cardiologie, Hôpital Simone Veil Groupe Hospitalier Eaubonne-Montmorency, France), Pierre Nadiras, MD (SMUR, Centre Hospitalier de Montfermeil, France), Olivier Nallet, MD (Service de Cardiologie, Centre Hospitalier de Montfermeil, France), Pierre Michaud, MD (Service de Cardiologie, Centre Hospitalier de Montfermeil, France), Brigitte Hennequin, MD (SMUR, Centre Hospitalier Delafontaine, St Denis, France), Christophe Adrie, MD (Service de Réanimation, Centre Hospitalier Delafontaine, St Denis, France), Franck Haziza, MD (Service de Cardiologie, Hôpital Foch, Suresnes, France), Jean-Philippe Kevorkian, MD (Service de Médecine, Hôpital Lariboisière, AP-HP, Paris, France), Marie-Reine Losser, MD PhD (Département d’Anesthésie-Réanimation-SMUR, Hôpital Lariboisière, AP-HP, Paris, France).

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Ducros, L., Logeart, D., Vicaut, E. et al. CPAP for acute cardiogenic pulmonary oedema from out-of-hospital to cardiac intensive care unit: a randomised multicentre study. Intensive Care Med 37, 1501–1509 (2011). https://doi.org/10.1007/s00134-011-2311-4

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