Abstract
BackgroundPatients with severe cardiogenic pulmonary edema (CPE) are frequently hypercapnic, possibly because of associated underlying chronic lung disease (CLD). Since hypercapnia has been associated with outcome, we aimed to identify factors associated to hypercapnia and its role on outcome of patients with CPE and no underlying CLD.MethodsObservational cohort study using data prospectively collected over a 3-year period. After excluding patients with any CLD or obstructive sleep apneas, all patients treated by non-invasive ventilation (NIV) for severe CPE were included. Hypercapnia was defined as PaCO2 >45 mmHg and non-rapid favorable outcome was defined as the need for intubation or continuation of NIV for more than 48 h.ResultsAfter excluding 60 patients with underlying CLD or sleep apneas, 112 patients were studied. The rates of intubation and of prolonged NIV were 6.3 % (n = 7) and 21.4 % (n = 24), respectively. Half of the patients (n = 56) had hypercapnia upon admission. Hypercapnic patients were older, more frequently obese, and were more likely to have a respiratory tract infection than non-hypercapnic patients. Hypercapnia had no influence on intubation rate or the need for prolonged NIV. However, patients with severe hypercapnia (PaCO2 >60 mmHg) needed longer durations of NIV and intensive care unit (ICU) stay than the others.ConclusionsAmong the patients admitted for severe CPE without CLD, half of them had hypercapnia at admission. Hypercapnic patients were older and more frequently obese but their outcome was similar compared to non-hypercapnic patients. Patients with severe hypercapnia needed longer durations of NIV than the others without increase in intubation rate.
Highlights
Patients with severe cardiogenic pulmonary edema (CPE) are frequently hypercapnic, possibly because of associated underlying chronic lung disease (CLD)
In patients admitted in intensive care unit (ICU) for acute exacerbation of chronic obstructive pulmonary disease (COPD), acute left ventricular dysfunction is identified as the main reason for acute respiratory failure in more than 40 % of the cases [15]
The diagnosis of CPE was defined as an acute respiratory failure in a patient with all of the following criteria: a compatible history of prior CPE or chronic heart failure, clinical signs of left and/or right cardiac failure, increase in NT-proBNP above 1000 pg/ml, bilateral alveolar and/or interstitial opacities on chest X-ray, and increase in left ventricular filling pressure on echocardiography indicated by a mitral E/A velocity ratio >2 using PW Doppler or E/e’ velocity >15 cm/s using tissue Doppler [23], in the absence of pneumonia
Summary
Patients with severe cardiogenic pulmonary edema (CPE) are frequently hypercapnic, possibly because of associated underlying chronic lung disease (CLD). Factors associated with hypercapnia during CPE are poorly understood, many patients with CPE may have an associated underlying chronic lung disease (CLD) promoting hypercapnia. The combination of left heart dysfunction and chronic lung disease is common; in a large clinical trial assessing NIV in more than 1000 patients with CPE [2], nearly 20 % of them had an underlying CLD. The overall rate of NIV failure in patients with acuteon-chronic lung disease is significantly higher than in those admitted for severe CPE [19] with an intubation rate reaching 25 to 30 % in recent surveys [20, 21]
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