OBJECTIVE: Continuous positive airway pressure (CPAP) is considered an effective nonpharmacologic method of treating patients with severe acute cardiogenic pulmonary edema. However, we hypothesized that bilevel noninvasive positive-pressure ventilation (NPPV), which combines both inspiratory pressure support and positive expiratory pressure, would unload the respiratory muscles and improve cardiac and hemodynamic function more effectively than CPAP. DESIGN: Randomized crossover study. SETTING: Critical care unit, Raymond Poincare Hospital. PATIENTS: Six consecutive patients with acute cardiogenic pulmonary edema. INTERVENTIONS: Patients were sequentially treated with 5 cmH2O CPAP, 10 cmH2O CPAP, and NPPV in a random order. MEASUREMENTS AND MAIN RESULTS: Cardiac and hemodynamic function and indexes of respiratory mechanics were measured at each treatment sequence. NPPV reduced the esophageal pressure swing and esophageal pressure-time product compared with baseline (p < 0.05). There was no reduction in esophageal pressure swing or esophageal pressure-time product with CPAP. NPPV and 10 cmH2O CPAP reduced the mean transmural right and left atrial filling pressures without a change in cardiac index. CONCLUSIONS: This study demonstrates that NPPV was more effective at unloading the respiratory muscles than CPAP in acute cardiogenic pulmonary edema. In addition, NPPV and 10 cmH2O CPAP produced a reduction in right and left ventricular preload, which suggests an improvement in cardiac performance.

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