Respiratory Management with Bi-level Positive Airway Pressure Ventilation for Acute Cardiogenic Pulmonary Edema

Non-invasive positive pressure ventilation (NIPPV) has long been used in the treatment of acute respiratory failure in patients with acute cardiogenic pulmonary edema (ACPE) and it has became a first line therapy for this kind of patients. Continuous positive airway pressure (CPAP) and bi-level positive airway pressure (bi-level PAP) are the two main NIPPV modalities. Though the results of meta-analysis of the difference in the effectiveness of these two modalities showed almost the same efficacy for ACPE patients, we have felt that bi-level PAP produces greater improvement in oxygenation parameters in some of the most severe type of ACPE patients. As the technique of using bi-level PAP is somewhat complex and requires more experience compared with CPAP, we designed a simple step-wise protocol for initiation and weaning of bi-level PAP. We have examined the clinical outcome of 45 patients with ACPE with whom this protocol was used and found that almost all patients successfully recovered from respiratory distress. There was no intubation nor complication related to their bi-level PAP treatment. In most of the cases, maximal end expiratory pressure was less than 7-cm H2O. The median duration was 8.0 hours. This simple step-wise bi-level PAP protocol for ACPE could be used even by co-medical staff safely and could facilitate quick and safe initiation and termination of the treatment.