EBM Consult

NonInvasive Ventilation for Severe Cardiogenic Pulmonary Edema


The use of non-invasive positive pressure ventilation (NIV) can reduce the risk for needing intubation and mechanical ventilation as well as rapid improvements in the clinical condition of the patient with cardiogenic pulmonary edema. The 2 most common forms of NIV include continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) with BiPAP usually being the most comfortable for most patients since it offers some time period of lower pressure.

Criteria for Using of CPAP or BiPAP:

Patients who are candidates for CPAP or BiPAP should meet the following general criteria:

  • Awake
  • Able to follow basic commands
  • Protect their airway
  • Not actively vomiting
  • Not having seizures

Initial BiPAP Settings:

  • Common initial inspiratory positive airway pressure (IPAP) is 10 cm H20 (larger patients may need 15 cm H20)
  • Expiratory positive airway pressure (EPAP) is 5 cm H20
  • Adjust from there usually by 2-5 cm H20
  • Rate of 10-12 breaths per minute (can increase rate if needing to get rid of more CO2)
  • FiO2 initially is set at 100% and then titrated down once stabilized

Initial CPAP Settings:

  • Initial pressure settings are usually around 10 cm H20 and then adjust based on patients comfort or clinical response. Pressures range from 4 to 20 cm H20.
  • Rate of 10-12 breaths per minute (can increase rate if needing to get rid of more CO2) 
  • FiO2 initially is set at 100% and then titrated down once stabilized 

Editor-in-Chief:  Anthony J. Busti, MD, PharmD, FNLA, FAHA
Last Reviewed:  February 2018

Original Studies

  • Bersten AD, et al. Treatment of severe cardiogenic pulmonary edema with continuous positive airway pressure delivered by face mask. N Engl J Med 1991;325:1825-1830. PubMed
  • Ducros L, et al. CPAP for acute cardiogenic pulmonary oedema from out of hospital to cardiac intensive care unit: a randomised multicentre study. Intensive Care Med 2011;37(9):1501-9. PubMed
  • Rasanen J, et al. Continuous positive airway pressure by face mask in acute cardiogenic pulmonary edema. Am J Cardiol 1985;55(4):296-300. PubMed
  • Mehta S, et al. Randomized, prospective trial of bilevel versus continuous positive airway pressure in acute pulmonary edema. Crit Care Med 1997;25(4):620-8. PubMed

Supporting Studies

  • Vital FM, et al. Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary edema. Cochrane Database Syst Rev 2013:CD005351 PubMed

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  • BiPAP Heart Failure, CPAP Heart Failure, BiPAP Cardiogenic Pulmonary Edema, CPAP Cardiogenic Pulmonary Edema, Noninvasive Ventilation, Non-invasive Positive Pressure Ventilation, NIV