A pressão positiva contínua das vias aéreas (CPAP) e a ventilação não invasiva bifásica podem ter efeitos benéficos no tratamento de pacientes com edema agudo pulmonar cardiogênico. Em um artigo feito por um grupo inglês, publicado recentemente na Emergency Medicine Journal, a eficácia de ambos os tratamentos foi avaliada numa comparação randomizada com a terapia padrão com oxigênio.
Sessenta pacientes com acidose aguda (pH<7.35), edema pulmonar cardiogênico, foram selecionados randomicamente para receberem oxigenoterapia convencional, CPAP (10 cm H2O) ou ventilação bifásica (IPAP 15 cm H2O, EPAP 5 cm H2O) fornecida por um ventilador padrão através de máscara facial. Os principais parâmetros de avaliação foram o sucesso terapêutico em duas horas e a mortalidade intra-hospitalar. As análises foram feitas através da intenção de tratar.
O sucesso terapêutico (definido como freqüência respiratória < 23 bpm, saturação de oxigênio > 90% e pH do sangue arterial > 7.35 (ou seja, reversão da acidose) no final do período de estudo de 2 horas) ocorreu em três (15%) pacientes do grupo controle, sete pacientes (35%) do grupo com CPAP e nove pacientes (45%) do grupo com ventilação bifásica (p = 0.116). Quatorze (70%) pacientes do grupo controle sobreviveram para a alta hospitalar, comparado com 20 (100%) do grupo com CPAP e 15 (75%) do grupo com ventilação bifásica (p = 0.029; teste de Fisher).
Os autores concluíram com este estudo que os pacientes com edema agudo pulmonar cardiogênico e acidose apresentaram maior propensão de sobrevida para a alta hospitalar quando tratados com CPAP do que com a ventilação bifásica ou terapia convencional com oxigênio. Não houve relação entre a sobrevida hospitalar e alterações fisiológicas precoces. As taxas de sobrevida foram similares a outros estudos apesar da baixa taxa de intubação endotraqueal.
Randomised controlled comparison of continuous positive airways pressure, bilevel non-invasive ventilation, and standard treatment in emergency department patients with acute cardiogenic pulmonary oedema - Emergency Medicine Journal - 2004; 21:155-161
Emerg Med J 2004; 21:155-161
© 2004 BMJ Publishing Group Ltd, British Association for Accident & Emergency Medicine, & Faculty of Accident & Emergency Medicine
Randomised controlled comparison of continuous positive airways pressure, bilevel non-invasive ventilation, and standard treatment in emergency department patients with acute cardiogenic pulmonary oedema
S D Crane1, M W Elliott2, P Gilligan3, K Richards4 and A J Gray5
1 Department of Emergency Medicine, Leeds General Infirmary, UK
2 Department of Respiratory Medicine, St James’s University Hospital, Leeds, UK
3 Department of Emergency Medicine, St James’s University Hospital
4 Department of General Medicine, Leeds General Infirmary
5 Department of Emergency Medicine, Edinburgh Royal Infirmary, UK
Correspondence to:
Dr S D Crane
Department of Emergency Medicine, York Hospital, Wigginton Road, York YO31 8HE, UK; seven.crane@york.nhs.uk
Background: Continuous positive airways pressure (CPAP) and bilevel non-invasive ventilation may have beneficial effects in the treatment of patients with acute cardiogenic pulmonary oedema. The efficacy of both treatments was assessed in the UK emergency department setting, in a randomised comparison with standard oxygen therapy.
Methods: Sixty patients presenting with acidotic (pH<7.35) acute, cardiogenic pulmonary oedema, were randomly assigned conventional oxygen therapy, CPAP (10 cm H2O), or bilevel ventilation (IPAP 15 cm H2O, EPAP 5 cm H2O) provided by a standard ventilator through a face mask. The main end points were treatment success at two hours and in-hospital mortality. Analyses were by intention to treat.
Results: Treatment success (defined as all of respiratory rate<23 bpm, oxygen saturation of>90%, and arterial blood pH>7.35 (that is, reversal of acidosis), at the end of the two hour study period) occurred in three (15%) patients in the control group, seven (35%) in the CPAP group, and nine (45%) in the bilevel group (p = 0.116). Fourteen (70%) of the control group patients survived to hospital discharge, compared with 20 (100%) in the CPAP group and 15 (75%) in the bilevel group (p = 0.029; Fisher’s test).
Conclusions: In this study, patients presenting with acute cardiogenic pulmonary oedema and acidosis, were more likely to survive to hospital discharge if treated with CPAP, rather than with bilevel ventilation or with conventional oxygen therapy. There was no relation between in hospital survival and early physiological changes. Survival rates were similar to other studies despite a low rate of endotracheal intubation.
