Intensive Care Med (2007) 33:374–375 DOI 10.1007/s00134-006-0472-3 CORRESPONDENCE Marco Cigada Giovanluigi Elia Michele Umbrello Matteo Giacomini Giovanni Mistraletti Concezione Tommasino Gaetano Iapichino Novel indications for the Boussignac CPAP valve Accepted: 27 October 2006 Published online: 9 December 2006 © Springer-Verlag 2006 Sir:The use of standard devices to provide continuous positive airway pressure (CPAP) outside the intensive care unit (ICU) environment may be awkward in the absence of ade- quate facilities. Therefore, simplified respirators and transportable CPAP systems are employed. However, these devices are still bulky, due to the presence of ventilatory circuits and separate additional machines. Recently, an innovative device has been proposed: the Boussignac CPAP valve [1] (Vygon, Ecouen, France) (Fig. 1). The valve is a small plastic tube (5.5 cm long, 1.3 cm internal diameter) that has to be attached to a face mask. The oxygen flow, connected to four micro-channels present in the wall of the valve, is accelerated, resulting in a PEEP level ranging from 2.5 to 10 cmH 2 O according to gas flow. Its efficacy during bronchoscopy in hypoxaemic patients [2] and in the treatment of acute cardiogenic pulmonary oedema, both in emergency departments [3, 4] and in extra-hospital set- tings [5], is reported. We believe that the Boussignac CPAP system, owing to its low weight, simplicity and small size, represents an optimal solution in a variety of clinical situations. Three illustrative cases are presented. A 50-year-old, morbidly obese (BMI 40.2) man was admitted to the emergency room due to a thoracic trauma. He presented with mild dysp- noea and tachypnoea (respiratory rate, RR 36 min –1 ). He underwent a lung CT scan, but, owing to the additional effect of obesity, supine positioning resulted in a rapidly progressive dyspnoea and SpO 2 of 84%. With the application of the Boussignac CPAP valve, the SpO 2 increased to 97% and eupnoea was maintained throughout the procedure. At the end of the investigation, which showed minor lung contusion, the patient was transferred to the ward. An 85-year-old woman was ad- mitted to a medical ward due to heart failure, acute-on-chronic renal failure, and confusional state. Her co-morbidities and general condi- tion made an aggressive respiratory strategy inappropriate. Due to poor peripheral vascular access, a central venous line was requested to provide medical treatment. Supine position was not tolerated (RR > 38 min –1 , SpO 2 84% in O 2 10 l/min within 1 min). Therefore, a Boussignac CPAP valve was applied during the procedure, resulting in improved oxy- genation parameters (SpO 2 > 93% and RR < 30/min). Fig. 1 The Boussignac CPAP valve (Vygon ® ) inserted into a face mask. To complete the system, only an oxygen tank is needed A 77-year-old woman presented with acute pulmonary oedema (dysp- noea, bilateral rales, SpO 2 82% with oxygen mask 10 l/min) during out- patient echocardiography as a result of an hypertensive crisis (systolic blood pressure, SBP 250 mmHg). A Boussignac CPAP was applied fol- lowed by standard medical treatment, resulting in a rapid clinical improve- ment (SpO 2 98%, RR 22 min –1 , SBP 140 mmHg while assisted). Maintain- ing CPAP support, the patient was transferred to the coronary unit (on the opposite side of our hospital) with the minimal hindrance of an O 2 tank. Within 30 min after arrival on the ward, CPAP could be stopped. Far from providing a “new” method for non-invasive respiratory assistance, the Boussignac valve represents an alternative to other de- vices to provide non-invasive CPAP. In appropriate settings (e. g. ICU, emergency department), other sys- tems may even prove more effective. However, the Boussignac valve’s unique characteristics of small size, technical simplicity and safety make it extremely suitable in a variety of clinical situations. The three case reports are mere examples of the use