Purpose: We identified risk factors for noninvasive ventilation (NIV) failure in patients with acute cardiogenic pulmonary edema (ACPE). Materials and methods: Weconducted an observational cohort study over a 3-year period in a 28-bed emergency intensive care unit (EICU) and prospectively included all consecutive patients inwhomNIVwas attempted as initial ventilatory support for ACPE. The primary outcome variables were NIV failure rate and risk factors for NIV failure. Results: Among the 118 patients in the study, NIV failed for 44 (37.3%) patients. Risk factors for NIV failure were Killip class IV (odds ratio [ OR], 28.56; 95% confidence interval [ CI], 2.17-375.73; p= 0.011), left ventricular ejection fraction (LVEF) <30% (OR, 9.54; 95% CI, 1.01-90.55; p = 0.050) and B-type natriuretic peptide (BNP) = 3350 pg/mL (OR, 39.63; 95% CI, 3.92-400.79; p = 0.002) at baseline, and fluid balance >= 400 mL within 24 h after ACPE (OR, 13.19; 95% CI, 1.18-147.70; p = 0.036). Conclusions: NIV failure occurred in 37.3% of ACPE patients in a real-world EICU. When patients had Killip class IV, a lower LVEF, a higher BNP, and amore positive fluid balance within 24 h after ACPE, the risk of failurewas higher. (C) 2017 Elsevier Inc. All rights reserved.