Applying CPAP in pulmonary edema

CPAP has an important role to play in improving outcomes for patients with acute cardiogenic pulmonary edema (ACPE). In this video, from our Noninvasive Ventilation Masterclass, we consider therapeutic goals in the context of ACPE patients and when to use CPAP in order to avoid endotracheal intubation.

Noninvasive ventilation (NIV) is a powerful therapy that clinicians can add to their ventilation toolboxes. This course will cover the indications for NIV, initiation and optimization, how to monitor patients on NIV, and how to wean them from it. We’ll delve into the controversial uses of NIV, when NIV is a first-line therapy, and how to rationally test its effectiveness in these situations.

Before we talk about applying CPAP, and pulmonary edema, just how does acute cardiogenic pulmonary edema come about? Increased left ventricular end diastolic pressures caused the left atrium to pump against an increased load, the atrium becomes overwhelmed, and an increased hydrostatic pressure gradient is created.

Eventually, the pulmonary interstitium becomes overloaded and widened due to the accumulation of fluid. This may cause both alveolar collapse and fluid accumulation in the alveoli. Both these processes limit the amount of oxygen that can get into the bloodstream, such that clinically, patients develop respiratory distress and hypoxic respiratory failure.

Acute cardiogenic pulmonary edema can happen very quickly, and has the possibility for high morbidity and even mortality. The in hospital mortality rate can be as high as 12%. Thankfully, continuous positive airway pressure that is CPAP has a role to improve the outcomes in patients with this disease.

Therapy for acute cardiogenic pulmonary edema is aimed at reducing cardiac preload, reducing afterload, removing excess volume and recruiting areas of lung with ventilation perfusion mismatch. non invasive ventilation can affect many of these issues all at once. non invasive ventilation for acute cardiogenic pulmonary edema was first evaluated in the 1930s but didn't receive widespread use until the 1970s.

In contemporary practice, the use of CPAP for acute pulmonary edema should be considered early and often. In fact, it has been strongly recommended in clinical practice guidelines. CPAP has improved a variety of clinical outcomes when studied, it decreases the respiratory rate shortens the length of stay in the ICU, and decreases the need for endotracheal intubation with a number needed to treat of eight.

That is, for every eight patients placed on non invasive ventilation for pulmonary edema, you will save one patient from possible endotracheal intubation. patients presenting with acute cardiogenic pulmonary edema have a lower mortality rate when non invasive ventilation is initiated earlier there management.

A Cochrane Systematic Review and meta analysis found a number needed to treat of 13 to improve mortality when non invasive ventilation was compared with standard therapy for acute cardiogenic pulmonary edema. So what is the target when using CPAP to treat acute cardiogenic pulmonary edema.

A good idea when initiating your patients on CPAP is to start with low pressures and titrating up to help them with compliance. However, when you have to act fast and initiate CPAP for your next pulmonary edema patient, it's worth knowing that most studies have found that CPAP from eight to 12 centimeters of water works best for their patients.

Now you're armed with the information needed to keep your next patient with acute pulmonary edema away from an endotracheal tube.
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