Is helmet CPAP first line pre-hospital treatment of presumed severe acute pulmonary edema?

Purpose: Non-invasive continuous positive airway pressure (CPAP) is effective in reducing intubation rate and mortality of patient with acute cardiogenic pulmonary edema (ACPE). We report our experience on pre-hospital application of CPAP by helmet as an adjunct to medical therapy or as a stand alone procedure in patient with presumed ACPE. Methods: In pre-hospital treatment of 62 patients with presumed ACPE, CPAP was added to standard medical treatment while in another 59 patients, CPAP was used as a sole therapy. Results: Helmet CPAP was feasible in all patients. No patient required pre-hospital intubation. In both groups, CPAP significantly improved oxygenation (SpO(2) went from 79 +/- 12 to 97 +/- 3% and from 81 +/- 13 to 98 +/- 3%), reduced respiratory rate (from 26 +/- 4 to 21 +/- 3 bpm and from 30 +/- 9 to 22 +/- 8 bpm) and improved hemodynamics, with a more pronounced decrease in blood pressure in the group with medical treatment than in the one without it. In the two cohorts, four and five patients were, respectively, intubated in Emergency Department and 11 and 9 eventually died. Conclusions: Helmet CPAP is feasible, efficient and safe in pre-hospital treatment of presumed ACPE. A significant improvement of physiological variables was observed also in the group treated with CPAP in the absence of a drug therapy. We propose helmet CPAP as first line pre-hospital treatment of presumed severe ACPE.