Abstract 4039: Continuous Positive Airway Pressure From Out-of-hospital Setting To Cardiac Intensive Care Unit In Acute Heart Failure: A Multicenter Randomized Study

Abstract

Purpose : Recent guidelines for acute heart failure (AHF) support the use of continuous positive airway pressure (CPAP) although its early use upstream intensive care unit (ICU) requires more evidence. The aim of this multicenter randomized study was to compare the effects of standard treatment of cardiogenic acute pulmonary oedema to CPAP when started in out-hospital setting and continued in ICU. Methods : AHF presenters with respiratory distress were enrolled by 10 emergency medical mobile services. Inclusion criteria were respiratory rate >25, pulse oxygen saturation <90% in air and Killip score ≥3. Each eligible patient was randomly assigned at home to receive standard treatment (ST) including oxygen, nitroglycerin, diuretic and inotropic drug as appropriate, or a combination of ST and CPAP (7.5–10 cmH 2 O). The primary end point, a composite of death, presence of intubation criteria or persistence at the second hour after inclusion, reappearance of the inclusion criteria or circulatory failure, was assessed within the first 48 hours after inclusion. The analysis was done by intention to treat. Results : 207 patients (80 ± 10 years, 59% females) were enrolled. Baseline characteristics and standard treatment were balanced between the 2 groups. The mean duration of CPAP was 1 hour prior to admission and 2 hours after admission. The primary end-point was observed in 36% of patients in ST and 21.5% in ST+CPAP (p=0.028). There was no difference in the rate of death (5% vs. 3.75% for ST and ST+CPAP, respectively), although the use of CPAP was associated with a significant reduction of persistent respiratory distress (26% vs 12%, p<0.01), of haemodynamic failure (6% vs 1%, p 0.05) and in the rate of intubation criteria (14% vs 4%, p=0.01). Clinical benefits of CPAP were found irrespective of left ventricular dysfunction and of normo/hypercapnia measured at inclusion. Conclusion : the use of CPAP upstream ICU and continued after admission improves improves early clinical outcome of patients presenting with cardiogenic acute pulmonary oedema.