American Journal of Emergency Medicine 31 (2013) 13221327

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American Journal of Emergency Medicine

journal homepage: www.elsevier.com/locate/ajem

Original Contribution

A comparison of bilevel and continuous positive airway pressure noninvasive

ventilation in acute cardiogenic pulmonary edema
Hui Li MM, Chunlin Hu MD, Jinming Xia MM, Xin Li MD, Hongyan Wei MM,
Xiaoyun Zeng MM, Xiaoli Jing MD
Department of Emergency, The First Afliated Hospital of Sun Yat-Sen University, Guangzhou 510080, China

a r t i c l e

i n f o

Article history:
Received 27 April 2013
Received in revised form 26 May 2013
Accepted 28 May 2013

a b s t r a c t
Background: Whether bilevel positive airway pressure (BiPAP) is advantageous compared with continuous
positive airway pressure (CPAP) in acute cardiogenic pulmonary edema (ACPO) remains uncertain. The aim of
the meta-analysis was to assess potential benecial and adverse effects of CPAP compared with BiPAP in
patients with ACPO.
Methods: Randomized controlled trials comparing the treatment effects of BiPAP with CPAP were
identied from electronic databases and reference lists from January 1966 to December 2012. Two
reviewers independently assessed study quality. In trials that fullled inclusion criteria, we critically
evaluate the evidence for the use of noninvasive ventilation on rates of hospital mortality, endotracheal
intubation, myocardial infarction, and the length of hospital stay. Data were combined using Review
Manager 4.3 (The Cochrane Collaboration, Oxford, UK). Both pooled effects and 95% condence intervals
(CIs) were calculated.
Results: Twelve randomized controlled trials with a total of 1433 patients with ACPO were included. The
hospital mortality (relative risk [RR], 0.86; 95% CI, 0.65-1.14; P = .46; I 2 = 0%) and need for requiring
invasive ventilation (RR, 0.89; 95% CI, 0.57-1.38; P = .64; I 2 = 0%) were not signicantly different
between patients treated with CPAP and those treated with BiPAP. The occurrence of new cases of
myocardial infarction (RR, 0.95; 95% CI, 0.77-1.17; P = .53, I 2 = 0%) and length of hospital stay
(RR, 1.01; 95% CI, 0.40 to 2.41; P = .98; I 2 = 0%) were also not signicantly different between the
2 groups.
Conclusions: There are no signicant differences in clinical outcomes when comparing CPAP vs BiPAP.
Based on the limited data available, our results suggest that there are no signicant differences in clinical
outcomes when comparing CPAP with BiPAP.
2013 Elsevier Inc. All rights reserved.

1. Background
Acute cardiogenic pulmonary edema (ACPO) is one of the most
important medical emergencies. Conventional treatment with oxygen, diuretics, and vasodilators could improve the symptoms of most
of the patients with ACPO. However, assisted ventilation may be
needed in patients still presenting hypoxemia and respiratory distress
after the initial conventional medical therapy, with the associated
potential for complications [1]. Continuous positive airway pressure
(CPAP) and bilevel positive airway pressure (BiPAP) are widely used
as an adjunct to treatment in acute respiratory failure. Over the past
10 years, application of noninvasive ventilation (NIV) has been

This study was supported by a grant from the TIANPU Fund (01200918). The funders
had no role in the study design, data collection, analysis, decision to publish, or the
preparation of the manuscript.
Correspondence author. Tel.: +86 20 87755766-8500; fax: +86 20 87755766
8773.
E-mail address: totohui1984@163.com (X. Jing).
0735-6757/$ see front matter 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajem.2013.05.043

suggested in association with the conventional medical treatment as

an effective therapeutic modality in ACPO. Acute pulmonary edema is
considered the second most common indication for NIV in clinical
practice [2,3]. The physiological effects of NIV include augmentation of
cardiac output and oxygen delivery, improved functional residual
capacity and respiratory mechanics, reduced effort in breathing, and
decreased left ventricular afterload [47]. As compared with CPAP,
some studies have shown that BiPAP reduce the work of breathing
and improve respiratory distress more effectively. Meanwhile, 2
studies suggested that patients treated with BiPAP had a higher
incidence of acute myocardial infarction (AMI) and a trend toward an
increase in creatine kinase [8,9]. A few recent meta-analyses could not
eliminate all the doubts at this regard because of the paucity of data
available and of the presence of confounding factors [10-13].
Considerable controversy remains over the short-term effect of NIV
on ACPO. In light of this uncertainty, we conducted systematic review
and meta-analysis, including several new randomized controlled
trials (RCTs), to investigate whether NIV improves survival and
whether BiPAP is more advantageous than CPAP.

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H. Li et al. / American Journal of Emergency Medicine 31 (2013) 13221327

authors have followed the recommended guidelines from the Quality

of Reporting of Meta-Analysis statement.
The selected articles were reviewed for the following study
characteristics: (1) studies were prospective randomized trials, (2)
adult patients undergoing ACPO, (3) documented inclusion and
exclusion criteria and comparability of groups at baseline, (4) bilevel
noninvasive positive pressure ventilation was compared with CPAP,
(5) documented criteria for invasive ventilation, and (6) a follow-up
period lasting at least the duration of hospitalization. Data selection
and data extracted were performed among pairs of independent
reviewers, and the results were conrmed by a third reviewer.
Discrepancies were discussed and adjudicated by the team consensus.
The quality assessment of the studies included based on 4 main
factors, including description of randomization, allocation concealment, description of withdrawals, and blinding outcome assessment
[14-18]. The primary outcomes for the included trials were the
hospital mortality and the proportion of patients requiring invasive
ventilation (or intubation). The other outcomes assessed in the metaanalysis included the length of hospital stay and incidence of new
myocardial infarction.

2316 potentially relevant trials

Limit to RCT (n = 127)

Limit to English (n = 118)

Limit to Adult (n = 97)

Potentially appropriate trials

for meta-analysis (n = 14)

Trials Excluded:
Not heart failure (n = 25)
Not between CPAP and
BiPAP(n = 50)
Other: (n = 8)

Trials Excluded:
Part of larger study (n = 1)
Trials included in
meta analysis (n = 12)

Crossover design (n = 1)

2.2. Statistical analyses

Fig. 1. Flow diagram of selection process to obtain articles chosen for meta-analysis.

2. Materials and methods

2.1. Search strategy and quality assessment
A literature search was conducted using EMBASE and MEDLINE
databases (1966December 2012). Only randomized controlled
clinical trials comparing BiPAP with CPAP in adult patients with
ACPO were included. During the electronic search for publications, the
key words used were as follows: congestive heart failure, heart
failure, pulmonary edema, cardiogenic pulmonary edema, lung
edema, positive pressure ventilation, noninvasive ventilation,
noninvasive positive pressure ventilation, NPPV, intermittent
positive-pressure ventilation, positive pressure respiration, intermittent positive-pressure breathing, BiPAP, and CPAP. The
searches were limited to English language publications. References
were examined to identify additional articles. Authors were contacted
to clarify details of trials if necessary. Studies using both CPAP and
BiPAP in the same group of patients in a crossover design were
excluded. In reporting the results of this systematic review, the

Data were checked and entered into the Review Manager (version
4.3; The Cochrane Collaboration, Oxford, UK) database for further
analysis. Using a xed-effects model, we calculated the risk ratios
(RRs) and 95% condence intervals for hospital mortality, need for
intubation, and incidence of new AMI and weighted mean differences
for the length of hospital stay. For continuous variables (length of
hospital stay), pooled estimates were only available if the mean and
SD were reported. The presence of heterogeneity between trials was
assessed using the 2 statistics, and the extent of inconsistency was
assessed using I 2 statistics.
3. Results
Twelve 12 articles with a total of 1433 patients fullled the criteria
for inclusion (Fig. 1) and compared CPAP with BiPAP, including 11
studies that were conducted in the emergency departments [7-9,14
22]. Trial characteristics are summarized in Table 1. All of the articles
were published in English, including data from 7 countries. Six studies
were multiple-center trials, whereas the others were conducted in 1
single center. The CPAP level used in these trials ranged from 5 to 15
cm H2O, although the most frequent pressure was 10 cm H2O. The
level of BiPAP was variable. Average inspiratory pressure airway

Table 1
Study characteristics, quality scores, and primary outcome data

Mehta et al [8]
Park et al [7]
Cross et al [21]
Crane et al [9]
Park et al [20]
Bellone et al [19]
Bellone et al [14]
Moritz et al [15]
Ferrari et al [18]
Gray et al [17]
Ferrari et al [16]
Nouira et a [22]

Year of study publication

Country

1997
2001
2003
2004
2004
2004
2005
2007
2007
2008
2010
2011

US
Brazil
Australia
UK
Brazil
Italy
Italy
France
Italy
UK
Italy
Tunisia

Quality score

N/A, not available. All data are expressed as CPAP/BiPAP.

a
Data are number of patients who died (total).
b
Data are number of patients receiving ventilation (total).
c
Data are number of new cases of AMI (total).
d
Data are mean length of hospital stay as mean SD (in days).

Mortalitya

Intubationb

Incidence of AMIc

Length of hospital stayd

1 (13)/1 (14)
1 (9)/0 (7)
5 (36)/3 (35)
0 (20)/5 (20)
1 (27)/2 (27)
2 (22)/0 (24)
1 (18)/0 (18)
4 (50)/8 (50)
2 (27)/3 (25)
53 (346)/54 (356)
2 (40)/7 (40)
3 (101)/5 (99)

1 (13)/1 (14)
3 (9)/1 (7)
9 (36)/3 (35)
N/A
2 (27)/2 (27)
1 (22)/2 (24)
1 (18)/2 (18)
2 (50)/1 (50)
0 (27)/1 (25)
8 (346)/12 (356)
0 (40)/3 (40)
7 (101)/10 (99)

4 (13)/10 (14)
1 (9)/0 (7)
N/A
6 (20)/9 (20)
N/A
3 (22)/2 (24)
N/A
3 (50)/2 (50)
6 (27)/4 (25)
94 (346)/95 (356)
0 (40)/2 (40)
2 (101)/4 (99)

N/A
N/A
N/A
N/A
11 8/10 7
N/A
N/A
N/A
12.923.7/9.97.4
N/A
10.515.41/10.068.13
11 4/9 3

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H. Li et al. / American Journal of Emergency Medicine 31 (2013) 13221327

Fig. 2. Effect of BiPAP and CPAP on mortality.

pressure ranged from 8 to 20 cm H2O, with 15 cm H2O being the most

repeated value. Conversely, expiratory pressure airway pressure was
set at 5 cm H2O in most trials. All studies had points deducted for
blinding because of the inherent difculty of blinding the treating
physicians to whether the patient is receiving CPAP or BiPAP.
Twelve studies compared the risk of hospital mortality between
patients treated with CPAP compared with BiPAP (Fig. 2).There were
no differences in hospital mortality identied between the groups. A
pooled analysis of 1433 patients conrmed no differences between
groups (RR, 0.86 [0.65-1.14]). The 2 test of heterogeneity ( 2 =
10.79) was not signicant (P = .46).
Eleven studies (n = 1385) assessed the risk of intubation in
patients treated with CPAP to BiPAP (Fig. 3). There was no statistical
difference between groups in either the individual studies or the
pooled analysis (RR, 0.89 [0.57-1.38]). The 2 test for heterogeneity
( 2 = 7.39) was not signicant (P = .64).
Nine studies compared CPAP with BiPAP for the occurrence of new
cases of myocardial infarction (Fig. 4). One of the studies demonstrated that higher rate of myocardial infarctions was associated with
the use of BiPAP [8]. The remainder of the studies showed little
evidence for a favorable trend between CPAP and BiPAP. The pooled
effect of 1272 patients suggested that there was an insignicant trend
toward an increase in new-onset AMI in patients treated with BiPAP
when compared with CPAP (RR, 0.95 [0.77-1.17]). The 2 test for
heterogeneity ( 2 = 7.03) was not signicant (P = .53).

Data on patients with length of hospital stay after initiation of

CPAP or BiPAP were limited (Fig. 5). Based on the pooled analysis of
the 4 trials (n = 386), there was an insignicant trend toward an
increase in length of hospital stay in patients between the 2 assisted
ventilatory modes (RR, 1.01 [ 0.40 to 2.41]). The 2 test for
heterogeneity ( 2 = 0.22) was not signicant (P = .98).
Meanwhile, the funnel plot indicated that the publication bias of
the review was acceptable (Fig. 6). The heterogeneity of all studies
included was not signicant (P N .10 in all heterogeneity assessments).
All studies achieved high-quality standard based on the quality
assessment (Table 2). Therefore, the evidence provided by the metaanalysis was convincing.

4. Discussion
This systematic review and meta-analysis investigates whether
there was a difference between CPAP and BiPAP with respect to
endotracheal intubation rate, mortality, incidence of AMI, and hospital
stay. Noninvasive ventilation was recommended in treatment of acute
heart failure by the European Society of Cardiology and American
Heart Association [23,24]. It would be advantageous to identify which
NIV strategy offers the most optimal therapeutic advantage. However,
one large randomized trial suggests no mortality benet associated
with NIV. The results of our systematic review are consistent with this

Fig. 3. Effect of BiPAP and CPAP on intubation.

H. Li et al. / American Journal of Emergency Medicine 31 (2013) 13221327

1325

Fig. 4. Effect of BiPAP and CPAP on AMI.

RCT, which shows no benet of NIV between ventilatory modes in the

management of patients presenting with ACPO.
In this meta-analysis, we did not compare a group of standard
oxygen therapy with CPAP or BiPAP, because it had been reported that
NIV delivered by either CPAP or BiPAP safely provides earlier
improvement and resolution of dyspnea, respiratory distress, and
metabolic abnormalities than standard oxygen therapy [9,17]. The
signicant benets of both CPAP and BiPAP are the reduction in the
need for intubation and a decrease in mortality and length of hospital
stay in ACPO, as seen in previous systematic review and meta-analysis
[25-27].
The main pathophysiologic mechanism of ventilatory pump failure
in patients with pulmonary edema is related to an increase in
inspiratory muscle energy demands [28]. Work of breathing may be
held responsible for increasing energy demands and elastic load
(alveolar congestion and, consequently, decreased lung compliance).
It is well known that administration of CPAP in patients with severe
decompensated heart failure reduced left ventricular lling pressure
and mitral regurgitation and increased left ventricular ejection
fraction [29-32]. Also, within 2 hours of administration, CPAP
improves systolic function, myocardial energy consumption, and
respiratory muscles workload in stable patients with heart failure
[32,33]. After a few weeks of administration, CPAP improves left
ventricular ejection fraction, left ventricular transmural pressure, and
left ventricular hypertrophy and cardiac work index [14]. In the
comparison of NIV modalities, BiPAP has the potential advantage over
CPAP of assisting the respiratory muscles during inspiration, which
would result in faster alleviation of dyspnea and exhaustion [34].
Bilevel positive airway pressure was more effective at unloading the
respiratory muscles than CPAP, while avoiding unnecessary airway
pressure and an excessive reduction in cardiac output [35]. Despite
the theoretical additional benets of BiPAP as compared with CPAP,
we observed no differences in therapeutic efcacy between the 2
noninvasive treatment methods. One study demonstrated that there
was no difference between the 2 ventilatory modes in a patient

diagnosed as having ACPO with hypercapnia [10]. The results suggests

that 15/5 cm H2O in the mode of BiPAP may equally have effects on
improving respiratory and hemodynamics with 10 cm H2O pressure
in CPAP, perhaps helping to explain our negative results on intubation
rate and mortality.
Although a preliminary study described a higher rate of AMI with
BiPAP and prematurely terminated their trial comparing CPAP with
BiPAP, Moritz et al [15] found a higher proportion of myocardial
infarction in patients who did not respond to treatment and
therefore did not recommend BiPAP in patients with myocardial
infarction. Nevertheless, Ferrari et al [16] described a good response
to nasal CPAP in patients with ACPO secondary to myocardial
infarction. No other trial ndings showed the same result between
both techniques. Several studies considered that the potential
advantage of BiPAP on faster alleviation of dyspnea and exhaustion
over CPAP was offset by the tendency toward an increased risk of
new myocardial infarction [18].
However, patients recruited in these studies were, by nature, at
high risk for developing AMI, either before or during the early phase of
hospitalization. Whether the infarcts preceded or were a consequence
of therapy should be identied. One possible explanation for the
higher rate of AMI results in the study of Mehta et al [8] is that the
etiologies of acute pulmonary edema are unbalanced at entrance. For
some studies, patients with AMI, presented increased concentrations
of troponin I or necessitating thrombolysis or primary angioplasty,
were excluded from the study [9,19,36,37]. Also, they had similar
rates of treatment-related myocardial infarction in patients receiving
CPAP and BiPAP. In our meta-analysis, BiPAP was proved a safe
modality for treating patients with ACPO in comparison with CPAP.
The other causes for the similar result in the incidence of AMI
between BiPAP and CPAP may be the use of nitrate. It was considered
that nitrates had conrmed efcacy in patients with ACPO [36]. One
study found that nitrate dose and use of prehospital nitrates were
associated with survival to discharge [9]. Furthermore, some investigators have reported that high-dose intravenous isosorbide-

Fig. 5. Effect of BiPAP and CPAP on hospital stay.

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H. Li et al. / American Journal of Emergency Medicine 31 (2013) 13221327

Fig. 6. Funnel plot for publication bias.

dinitrate administration was more effective than BiPAP ventilation in

controlling pulmonary edema [37]. In our meta-analysis, the dose of
nitrate in ACPO was not reported in half of the pooled studies,
whereas in the other half of studies, patients received remarkably
different amounts of nitrate treatment. It is hard to relate the use of
nitrate combined with BiPAP or CPAP to a lower mortality.

pulmonal edema. Our data can be added to the accumulating evidence

underscoring the same effect of BiPAP compared with CPAP on
mortality, intubation rate, and length of stay in hospital in ACPO.
Importantly, no true difference or trend toward an increase in AMI
rates was found with the use of BiPAP.
References

5. Limitations
In this meta-analysis, although the inclusion criteria, intervention
protocols, and baseline characteristics were similar between the 2
groups, the inability to adjust statistically for differences in other
factors beyond treatment group assignment could have inuenced the
nal results. First, meta-analyses are prone to bias. The quality of trials
can affect the direction and magnitude of treatment effect in metaanalyses. A second limitation is that the treatment was not blinded.
Because the physicians who decided when to initiate endotracheal
intubation or to cease NIV were not blinded, introducing the
possibility of investigator bias might have affected the results. Future
NIV studies should consider blinding the physician to the mode of NIV
used. Most of these studies were powered for intubation and not for
mortality, AMI, and length of hospital stay. Most of the included
studies have small numbers of participants, thereby reinforcing the
necessity of our meta-analysis.
6. Conclusion
According to all available data, there is no evidence to suggest
superiority of either CPAP or BiPAP in patients with acute cardiogenic

[1] British Thoracic Society Standards of Care Committee. Non-invasive ventilation in

acute respiratory failure. Thorax 2002;57:192211.
[2] Antonelli M, Conti G, Moro ML, Esquinas A, Gonzalez-Diaz G, Confalonieri M, et al.
Predictors of failure of noninvasive positive ventilation in patients with acute
hypoxemic respiratory failure. Intensive Care Med 2001;27:171828.
[3] Burns KE, Sinuff T, Adhikari NK, Meade MO, Heels-Ansdell D, Martin CM, et al.
Bilevel noninvasive positive pressure ventilation for acute respiratory failure. Crit
Care Med 2005;33:147783.
[4] Baratz DM, Westbrook PR, Shah PK, Mohsenifar Z. Effect of nasal continuous
positive airway pressure on cardiac output and oxygen delivery in patients with
congestive heart failure. Chest 1992;102:1397401.
[5] Lenique F, Habis M, Lofaso F, Dubois-Rand JL, Harf A, Brochard L. Ventilatory and
hemodynamic effects of continuous positive airway pressure in left heart failure.
Am J Respir Crit Care Med 1997;155:5005.
[6] International Consensus Conference in Intensive Care Medicine. Noninvansive
positive pressure ventilation in acute respiratory failure. Am J Respir Crit Care Med
2001;163:28391.
[7] Park M, Lorenzi-Filho G, Feltrim MI, Viecili PR, Sangean MC, Volpe M, et al. Oxygen
therapy, continuous positive airway pressure, or noninvasive bilevel positive
pressure ventilation in the treatment of acute cardiogenic pulmonary edema. Arq
Bras Cardiol 2001;76:22130.
[8] Mehta S, Jay GD, Woolard RH, Hipona RA, Connolly EM, Cimini DM, et al.
Randomized, prospective trial of bilevel versus continuous positive airway
pressure in acute pulmonary edema. Crit Care Med 1997;25:6208.
[9] Crane SD, Elliott MW, Gilligan P, Richards K, Gray AJ. Randomized controlled
comparison of continuous positive airway pressure, bilevel non-invasive
ventilation and standard treatment in emergency department patients with
acute cardiogenic pulmonary oedema. Emerg Med J 2004;21:15561.

Table 2
Main quality assessment of included studies
Year

Author

Study design

Description of randomization

Allocation concealment

Description of withdrawals

Blinding outcome assessment

2007
2008
2004
2005
2001
2004
1997
2004
2003
2010
2011
2007

Ferrari et al [18]
Gray et al [17]
Bellone et al [19]
Bellone et al [14]
Park et al [7]
Crane et al [9]
Mehta et al [8]
Park et al [20]
Cross et al [21]
Ferrari et al [16]
Nouira et a [22]
Moritz et al [15]

RCT
RCT
RCT
RCT
RCT
RCT
RCT
RCT
RCT
RCT
RCT
RCT

+
+
+
+

+
+
+

+
+
+

+
+
+
+

+
+
+

+
+
+

+
+
+
+

+
+
+

+
+
+

H. Li et al. / American Journal of Emergency Medicine 31 (2013) 13221327

[10] Peter JV, Moran JL, Phillips-Hughes J, Graham P, Bersten AD. Effect of non-invasive
positive pressure ventilation (NIPPV) on mortality in patients with acute
cardiogenic pulmonary oedema: a meta-analysis. Lancet 2006;367:115563.
[11] Ho KM, Wong K. A comparison of continuous and bi-level positive airway pressure
non-invasive ventilation in patients with acute cardiogenic pulmonary oedema: a
meta-analysis. Crit Care 2006;10:R49.
[12] Masip J, Roque M, Snchez B, Fernndez R, Subirana M, Expsito JA. Noninvasive
ventilation in acute cardiogenic pulmonary edema. JAMA 2005;294:312430.
[13] Collins SP, Mielniczuk LM, Whittingham HA, Boseley ME, Schramm DR, Storrow
AB. The use of noninvasive ventilation in emergency department patients with
acute cardiogenic pulmonary edema: a systematic review. Ann Emerg Med
2006;48:2609.
[14] Bellone A, Vettorello M, Monari A, Cortellaro F, Coen D. Noninvasive pressure
support ventilation vs continuous positive airway pressure in acute hypercapnic
pulmonary edema. Intensive Care Med 2005;31:80711.
[15] Moritz F, Brousse B, Gelle B, Chajara A, L'Her E, Hellot MF, et al. Continuous
positive airway pressure versus bilevel noninvasive ventilation in acute
cardiogenic pulmonary edema: a randomized multicenter trial. Ann Emerg Med
2007;50:66675.
[16] Ferrari G, Milan A, Groff P, Pagnozzi F, Mazzone M, Molino P, et al. Continuous
positive airway pressure vs. pressure support ventilation in acute cardiogenic
pulmonary edema: a randomized trial. J Emerg Med 2010;39(5):67684.
[17] Gray A, Goodacre S, Newby DE, Masson M, Sampson F, Nicholl J. 3CPO trialists.
Noninvasive ventilation in acute cardiogenic pulmonary edema. N Engl J Med
2008;359:14251.
[18] Ferrari G, Olliveri F, De Filippi G, Milan A, Apr F, Boccuzzi A, et al. Noninvasive
positive airway pressure and risk of myocardial infarction in acute cardiogenic
pulmonary edema. Chest 2007;132:18049.
[19] Bellone A, Monari A, Cortellaro F, Vettorello M, Arlati S, Coen D. Myocardial
infarction rate in acute pulmonary edema: noninvasive pressure support
ventilation versus continuous positive airway pressure. Crit Care Med
2004;32(9):18605.
[20] Park M, Sangean MC, Volpe Mde S, Feltrim MI, Nozawa E, Leite PF, et al.
Randomized, prospective trial of oxygen, continuous positive airway pressure, and
bilevel positive airway pressure by face mask in acute cardiogenic pulmonary
edema. Crit Care Med 2004;32(12):240715.
[21] Cross AM, Cameron P, Kierce M, Ragg M, Kelly AM. Non-invasive ventilation in
acute respiratory failure: a randomised comparison of continuous positive airway
pressure and bi-level positive airway pressure. Emerg Med J 2003;20:5314.
[22] Nouira S, Boukef R, Bouida W, Kerkeni W, Beltaief K, Boubaker H, et al. Noninvasive pressure support ventilation and CPAP in cardiogenic pulmonary edema:
a multicenter randomized study in the emergency department. Intensive Care
Med 2011;37:24956.
[23] ESC guidelines for the diagnosis and treatment of acute and chronic heart failure
2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart
Failure 2012 of the European Society of Cardiology. Developed in collaboration
with the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail 2012;14(8):
80369.

1327

[24] Weintraub NL, Collins SP, Pang PS, Levy PD, Anderson AS, Arslanian-Engoren C,
et al. American Heart Association Council on Clinical Cardiology and Council on
Cardiopulmonary, Critical Care, Perioperative and Resuscitation. Acute heart
failure syndromes: emergency department presentation, treatment, and disposition: current approaches and future aims: a scientic statement from the
American Heart Association. Circulation 2010;122(19):197596.
[25] Bersten AD, Holt AW, Vedig AE, Skowronski GA, Baggoley CJ. Treatment of severe
cardiogenic pulmonary edema with continuous positive airway pressure
delivered by face mask. N Engl J Med 1991;325:182530.
[26] Chadda K, Annane D, Hart N, Gajdos P, Raphal JC, Lofaso F. Cardiac and respiratory
effects of continuous positive airway pressure and noninvasive ventilation in
acute cardiac pulmonary edema. Crit Care Med 2002;30:245761.
[27] Bellone A, Barbieri A, Ricci C, Iori E, Donateo M, Massobrio M, et al. Acute effects of
non-invasive ventilatory support on functional mitral regurgitation in patients with
exacerbation of congestive heart failure. Intensive Care Med 2002;28:134850.
[28] Bendjelid K, Schtz N, Suter PM, Fournier G, Jacques D, Fareh S, et al. Does
continuous positive airway pressure by face mask improve patients with acute
cardiogenic pulmonary edema due to left ventricular diastolic dysfunction? Chest
2005;127:10538.
[29] Yoshinaga K, Burwash IG, Leech JA, Haddad H, Johnson CB, deKemp RA. The effects
of continuous positive airway pressure on myocardial energetics in patients with
heart failure and obstructive sleep apnea. J Am Coll Cardiol 2007;49:4508.
[30] Naughton MT, Rahman MA, Hara K, Floras JS, Bradley TD. Effect of continuous
positive airway pressure on intrathoracic and left ventricular transmural
pressures in patients with congestive heart failure. Circulation 1995;91:172531.
[31] Tkacova R, Rankin F, Fitzgerald FS, Floras JS, Bradley TD. Effects of continuous
positive airway pressure on obstructive sleep apnea and left ventricular afterload
in patients with heart failure. Circulation 1998;98:226975.
[32] Wysocki M. Noninvasive ventilation in acute cardiogenic pulmonary edema:
better than continuous positive airway pressure? Intensive Care Med 1999;25:
12.
[33] Nava S, Carbone G, DiBattista N, Bellone A, Baiardi P, Cosentini R, et al. Noninvasive
ventilation in cardiogenic pulmonary edema: a multicenter randomized trial. Am J
Respir Crit Care Med 2003;168:14327.
[34] Rusterholtz T, Kempf J, Berton C, Gayol S, Tournoud C, Zaehringer M, et al.
Noninvasive pressure support ventilation (NIPSV) with face mask in patients with
acute pulmonary edema (ACPE). Intensive Care Med 1999;25:218.
[35] Takeda S, Nejima J, Takano T, Nakanishi K, Takayama M, Sakamoto A, et al. Effect of
nasal continuous positive airway pressure on pulmonary edema complicating
acute myocardial infarction. Japan Circ J 1998;62:5538.
[36] Cotter G, Metzkor E, Kaluski E, Faigenberg Z, Miller R, Simovitz A, et al.
Randomised trial of high-dose isosorbide dinitrate plus low-dose furosemide
versus high-dose furosemide plus low-dose isosorbide dinitrate in severe
pulmonary oedema. Lancet 1998;351:38993.
[37] Sharon A, Shpirer I, Kaluski E, Moshkovitz Y, Milovanov O, Polak R, et al. High-dose
intravenous isosorbide-dinitrate is safer and better than Bi-PAP ventilation
combined with conventional treatment for severe pulmonary edema. J Am Coll
Cardiol 2000;36(3):8327.