NON - INVASIVE VENTILATION IN

ACUTE CARDIOGENIC PULMONARY

OEDEMA

ANDREW ADAIR
MIDDLESBOROUGH GENERAL HOSPITAL
AIMS AND OBJECTIVES
 Epidemiology of Heart Failure

 Pathophysiology of Cardiogenic Pulmonary Oedema

 Effect of Positive Airway Pressure Ventilation on

Respiratory and Cardiovascular System

 Review of Literature - CPAP or BiPAP?

 Results / Conclusions

 ? Role in Accident and Emergency

 STATISTICS FOR HEART FAILURE ( 1 )
 Limited UK data

 Incidence 1.4 / 1000 population in males

1.2 / 1000 population in females ( HILLINGDON )
 Total of 63,000 new cases / year ( HILLINGDON )

 Prevalence 3% >45yrs (HEART OF ENGLAND SCREENING STUDY )

878,000 in UK today
 Increases with age
65-74yr 1:35
75-84yr 1:15
>85yr 1:7
 Increasing rate BUT no evidence of increasing prevalence in UK!
 STATISTICS FOR HEART FAILURE ( 2 )
 Mortality 10,000 officially recorded deaths in 2000

 Prognosis 40% death within 1 year

>70% at 5 years ( HILLINGDON )

 ‘Estimate at Mortality Rates’

24,000 deaths in 2000
5% of all deaths
 50% of deaths are ‘sudden’

 Economics 86,000 admissions ( 13 days )

£379 million
Total cost / year is £625 million
PATHOPHYSIOLOGY OF C.P.O ( 1 )

“Acute CPO is a sudden rise in pulmonary

capillary pressure causing engorgement
of pulmonary vessels ( blood and
lymphatic), and exudation into the
interstitial and alveolar spaces,
manifested by varying degrees of
respiratory distress.”

 Left Ventricular Failure

 Mitral Stenosis
 PATHOPHYSIOLOGY OF C.P.O ( 2 )
weak left ventricle

increase back pressure, decrease CO

increase BP and fluid volume, increasing LV pressure

pooling in pulmonary blood vessels

fluid leakage and accumulation in interstitial tissue

poor lung expansion

poor gas exchange and pulmonary blood flow

 Important sympathetic reflex component

EFFECT OF POSITIVE AIRWAY PRESSURE
VENTLATION ( 1 )

CPAP
 Improved lung mechanics :
– recruits collapsed lung units
– redistribution of lung water
– greater area for gas exchange
– reduces intrapulmonary shunt
– enhances pulmonary compliance
– reduces work of breathing
– negates intrinsic PEEP
EFFECT OF POSITIVE AIRWAY PRESSURE
VENTLATION ( 2 )

CPAP
 Cardiovascular status
– decreases venous return ( therefore preload )
– reduction in afterload
– reduces transmural pressure
– no change in myocardial contractiity

– improved ejection fraction without increase in

myocardial oxygen consumption
EFFECT OF POSITIVE AIRWAY PRESSURE
VENTLATION ( 3 )
BiPAP
 Physiological advantages of CPAP through EPAP

 assistance of spontaneous ventilation

 promotes inhibition of the diaphragm - reduced work of
breathing with increase in tidal volume / gas exchange

 BUT : ? larger decrease in BP

? greater variation in intrathoracic pressure
? greater decrease in venous return
? Reduced myocardial perfusion
EVIDENCE FOR USE OF CPAP IN ACPO (1)
 First reported 1936 ( Poulton ) - use in ‘cardiac asthma’

 1960’s : benefit of PEEP in mechanical ventilation

 ‘CPAP’ first described in 1971 ( Gregory ) - neonates

 Many reports of successful treatment of ACPO with CPAP but

still very variable use :
1. Problems with original studies
2. No reporting on adverse effects
3. “research transfer”
4. Availability and varying experience
EVIDENCE FOR USE OF CPAP IN ACPO (2)

 5 Prospective Randomised Controlled trials

comparing CPAP with standard medical therapy

 4 ‘review’ articles :
- 1998 : Pang et al ( Chest )
- 1999 : Cross ( EMJ )
- 2000 : Kosowsky ( Therapeutics )
- 2000 : Ratchford ( CTR )
- 2002 : British Thoracic Society Guidelines

 Many case series reports

Rasanen 40 patients Intubation 6/20 v 12/20 NS
1985 CPAP (20)
Finland V Mortality 17/20 v 14/20 NS
Control (20)

Bersten 39 patients Intubation 0/19 v 7/20 <0.005

1991 CPAP (19)
Australia V Mortality 2/19 v 4/20 NS
Control (20)
Lin 55 patients Intubation 7/25 v 17/30 <0.05
1991 CPAP (25)
Taiwan V Mortality 2/25 v 4/30 NS
Control (30)

Lin 100 patients Intubation 8/50 v 18/50 <0.01

1995 CPAP (50)
Taiwan V Mortality 4/50 v 6/50 NS
Control (50)

Takeda 22 patients Intubation 2/11 v 8/11 <0.03

1998 CPAP (11)
Japan V Mortality 1/11 v 7/11 0.02
Control (11)
EVIDENCE FOR USE OF CPAP IN ACPO (4)
 In CPAP group all studies showed a significant
improvement in :
Respiratory status
Cardiovascular parameters
Blood gas analysis

 No reported complications in any study

 Case studies reported : FAILURE TO TOLERATE, skin

ulceration, corneal abrasions, pneumomediastinum,
pneumocephalus, sinus / ear pain, gastric insufflation
 EVIDENCE FOR USE OF CPAP IN ACPO (5)
POOLING OF DATA

 Pang (1998) showed an ARR for intubation of 26% (95%

CI -13 to -38%)
 NNT = 4
 also showed “a trend to decrease in mortality” with an
ARR of 6.6% ( 95% CI +3 to -16%)

 John Wright pooled above results with Takeda trial

looking at mortality rates (short term) showing a ARR of
13% (95% CI -3.4 to -24.2%)
 EVIDENCE FOR USE OF CPAP IN ACPO (6)

BRITISH THORACIC SOCIETY

“Non-invasive Ventilation in Acute Respiratory Failure”

Standards of Care Report 2002

“…CPAP has been shown to be effective in patients

with Cardiogenic Pulmonary Oedema who remain
hypoxic despite maximal Medical management.” (B)

WHAT ABOUT BiPAP ?

 EVIDENCE FOR USE OF BiPAP IN ACPO (1)
 Efficacy considered ambiguous when compared to CPAP
despite theoretical advantage

 Introduced late 1980’s

 Shown to reduce need for intubation in ARF

 Meta-analysis (Keenan 1997, Critical Care Medicine) showed

that efficacy was limited to patients were the specific cause
of ARF was an exacerbation of COPD (Hypercapnic type II
Respiratory Failure)

 BUT has been shown to successfully treat ACPO

 EVIDENCE FOR USE OF BiPAP IN ACPO (2)

 1 Randomised Controlled Trial comparing BiPAP to

standard medical therapy

 3 Randomised Controlled Trials comparing with other

treatments :
- CPAP or Oxygen
- iv Nitrates
- CPAP

 Several case series

 Masip 37 patients Intubation 1/19 v 6/18 0.037
2000 BiPAP (19)
Spain V Mortality 0/19 v 2/18 NS
Control (18)

Park 26 patients Intubation 0/7 v 3/9 v 4/10 <0.05

2001 BiPAP (7)
Brazil V Mortality 0/7 v 1/9 v 0/10 NS
CPAP (9)
V
Control (10)

 Both studies showed a faster recovery of vital signs and

improvement in blood gas analysis in the BiPAP group.

 Masip resolution time of 30 min v 105 min (p 0.002)

(Clinical improvement with O2 sat of >96% and RR <30/min)

 Masip (level 1b : EBM) ARR 28.1% (95% CI 4.09% - 52.1%)

NNT of 4 at 10 hrs
 EVIDENCE FOR USE OF BiPAP IN ACPO (4)
Wood et al (1998)

 RCT of BiPAP in variety of causes of ARF ( ACPO 10/27)

 Faster improvement in all parameters

 No difference in intubation rates but INC. in mortality

 ? Bias in treatment :
reluctance to abandon BiPAP
delayed intubation
inc. multi -organ system derangements
EVIDENCE FOR USE OF BiPAP IN ACPO (5)
Sharon 40 patients Intubation 16/20 v 2/20 NS
2000 BiPAP (20)
Israel V Mortality 2/20 v 0/20 0.0004
Repeated
Iv Nitrates (20) MI 11/20 v 2/20 0.006

 Combined end point : 17/20 v 5/20 ( p 0.0003)

 Slower rate of improvement in BiPAP group ( p 0.017)

 Premature Termination by Safety Committee

 ( Pre- hospital setting)

EVIDENCE FOR USE OF BiPAP IN ACPO (6)
 Despite negative reports there still exists much
evidence supporting BiPAP in ACPO

 Intubation rates from 0 - 44%

 Mortality rates from 0 - 22%

 Many find it difficult to support BiPAP in a condition

already treated successfully by CPAP

BiPAP or CPAP ?
 CPAP OR BiPAP INTREATMENT OF ACPO (1)
 In addition to PARK (BiPAP) there is 1 Randomised
Controlled Trial and 1 Retrospective Analysis

Mehta 27 patients Intubation 1/14 v 1/13 NS

1997 BiPAP (14)
USA V Mortality 1/14 v 2/13 NS
CPAP (13)
MI 10/14 v 4/13 0.05

 BiPAP group : improvement in PaC02, pH, HR, RR

(p <0.05)

 CPAP group : improvement in RR only (p <0.05)

 CPAP OR BiPAP INTREATMENT OF ACPO (2)
Reason for increased MI’s ?

 Greater variation in intrathoracic pressure and VR

 Greater leak with nasal masks

 No adverse haemodynamic effects of BiPAP in other studies

 On entry to study a greater number of BiPAP patients had

chest pain and elevated cardiac enzymes ( 10 v 4 p 0.05)

MI’s already underway at enrollment ?

 CPAP OR BiPAP INTREATMENT OF ACPO (3)
Ferrari 52 patients Intubation O/27 v 3/25
2000 BiPAP (27)
Italy V Mortality 0/27 v 2/25
CPAP (25)
MI 5/27 v 6/25

(4 from each group had elevated enzymes and ECG changes)

 Both groups showed statistically significant improvements in

PaO2, PaCO2, RR, pH, HR

 No association found between BiPAP and MI’s

 “ Increased trend toward prevention of intubation”

 CONCLUSIONS FROM STUDIES (1)

 Modest evidence to support CPAP in ACPO associated with

decreased intubation rates and “trend towards decrease in
mortality”

 Also favourable support for BiPAP but largely from case

series and anecdotal reports

 Little evidence to support initial hypothesis that BiPAP

provides additional benefit over CPAP
( ??? Unless associated with greatly elevated PACO2 ???)
 CONCLUSIONS FROM STUDIES (2)
BRITISH THORACIC SOCIETY

“Non-invasive Ventilation in Acute Respiratory Failure”

Standards of Care Report 2002

“…CPAP has been shown to be effective in patients

with Cardiogenic Pulmonary Oedema who remain
hypoxic despite maximal Medical management.
NIV should be reserved for patients in whom CPAP
is unsuccessful.” (B)
USE OF NIV IN A&E : EVIDENCE & CONCERNS (1)
 Most trials conducted in ITU / HDU setting

 Many A&E patients improve after initial therapy

 Intubation rates in controls considered high (~60%) -

inevitable that NIV will reduce intubation rate ?
Leeds 104 ACPO patients : all acidotic on arrival
89% improved clinically and pH
11% intubated
would NIV alter this rate ?

 May delay or prevent intubation (concerns regarding

complications of intubation)
USE OF NIV IN A&E : EVIDENCE & CONCERNS (2)
 Increasing incidence of heart failure

 Evidence does exist for CPAP as “first line treatment”

(Australia, France)

 L`Her (1998) : improvement in mortality from 20% - 11%

 Kelly : chart review of 75 patients in urban A&E

safe and effective
intubation rate of 4%
no increase in mortality
average duration of 1.9 hours
no delay in clearance of patients from department
claimed did not create extra workload
USE OF NIV IN A&E : EVIDENCE & CONCERNS (3)

 Written guidelines tailored to local expertise

 Appropriate training

 With appropriate patient selection and careful

monitoring I feel that NIV (CPAP) should be
considered an acceptable addition to the
treatment of ACPO in A&E
ANY QUESTIONS ?