originalarticleThenewenglandjournalofmedicinenengljmed359;2www.nejm.orgjuly10,2008142NoninvasiveVentilationinAcuteCardiogenicPulmonaryEdemaAlasdairGray,M.D.,SteveGoodacre,Ph.D.,DavidE.Newby,M.D.,MoyraMasson,M.Sc.,FionaSampson,M.Sc.,andJonNicholl,M.Sc.,forthe3CPOTrialists*FromtheRoyalInfirmaryofEdinburgh,Edinburgh(A.G.,M.M.),theUniversityofSheffield,Sheffield(S.G.,F.S.,J.N.),andtheUniversityofEdinburgh,Edinburgh(D.E.N.)—allintheUnitedKingdom.AddressreprintrequeststoDr.GrayattheDepartmentofEmergencyMedicine,RoyalInfirmaryofEdinburgh,LittleFrance,EdinburghEH164SA,UnitedKingdom,oratalasdair.gray@luht.scot.nhs.uk.*TheparticipantsintheThreeInterven-tionsinCardiogenicPulmonaryOedema(3CPO)trialarelistedintheAppendix.NEnglJMed2008;359:142-51.Copyright©2008MassachusettsMedicalSociety.AbstractBackgroundNoninvasiveventilation(continuouspositiveairwaypressure[CPAP]ornoninvasiveintermittentpositive-pressureventilation[NIPPV])appearstobeofbenefitintheimmediatetreatmentofpatientswithacutecardiogenicpulmonaryedemaandmayreducemortality.Weconductedastudytodeterminewhethernoninvasiveventilationreducesmortalityandwhetherthereareimportantdifferencesinoutcomeassoci-atedwiththemethodoftreatment(CPAPorNIPPV).MethodsInamulticenter,open,prospective,randomized,controlledtrial,patientswereassignedtostandardoxygentherapy,CPAP(5to15cmofwater),orNIPPV(inspiratorypressure,8to20cmofwater;expiratorypressure,4to10cmofwater).Theprimaryendpointforthecomparisonbetweennoninvasiveventilationandstandardoxygentherapywasdeathwithin7daysaftertheinitiationoftreatment,andtheprimaryendpointforthecomparisonbetweenNIPPVandCPAPwasdeathorintubationwithin7days.ResultsAtotalof1069patients(mean[±SD]age,77.7±9.7years;femalesex,56.9%)wereas-signedtostandardoxygentherapy(367patients),CPAP(346patients),orNIPPV(356patients).Therewasnosignificantdifferencein7-daymortalitybetweenpatientsreceivingstandardoxygentherapy(9.8%)andthoseundergoingnoninvasiveventi-lation(9.5%,P=0.87).Therewasnosignificantdifferenceinthecombinedendpointofdeathorintubationwithin7daysbetweenthetwogroupsofpatientsundergoingnoninvasiveventilation(11.7%forCPAPand11.1%forNIPPV,P=0.81).Ascomparedwithstandardoxygentherapy,noninvasiveventilationwasassociatedwithgreatermeanimprovementsat1hourafterthebeginningoftreatmentinpatient-reporteddyspnea(treatmentdifference,0.7onavisual-analoguescalerangingfrom1to10;95%confidenceinterval[CI],0.2to1.3;P=0.008),heartrate(treatmentdifference,4beatsperminute;95%CI,1to6;P=0.004),acidosis(treatmentdifference,pH0.03;95%CI,0.02to0.04;P<0.001),andhypercapnia(treatmentdifference,0.7kPa[5.2mmHg];95%CI,0.4to0.9;P<0.001).Therewerenotreatment-relatedad-verseevents.ConclusionsInpatientswithacutecardiogenicpulmonaryedema,noninvasiveventilationinducesamorerapidimprovementinrespiratorydistressandmetabolicdisturbancethandoesstandardoxygentherapybuthasnoeffectonshort-termmortality.(CurrentControlledTrialsnumber,ISRCTN07448447.)TheNewEnglandJournalofMedicineDownloadedfromnejm.orgonMarch22,2011.Forpersonaluseonly.Nootheruseswithoutpermission.Copyright©2008MassachusettsMedicalSociety.Allrightsreserved.NoninvasiveVentilationinAcuteCardiogenicPulmonaryEdemanengljmed359;2www.nejm.orgjuly10,2008143Acutecardiogenicpulmonaryedemaisacommonmedicalemergencythatac-countsforupto1millionhospitaladmis-sionsforacuteconditionsperyearintheUnitedStates.1Itisal...
