Non-invasive positive pressure ventilation for cardiogenic pulmonary oedema

Acute heart failure has a high incidence in the general population and may lead to  the accumulation of fluid in the lungs, which is called acute cardiogenic pulmonary oedema (ACPE). This review aimed to determine the effectiveness and safety of non-invasive positive pressure ventilation (NPPV) (continuous positive airway pressure (CPAP) or bilevel NPPV) plus standard medical care, compared with standard medical care alone in adults with ACPE. We included 32 studies (2916 participants) of generally low or uncertain risk of bias. Results from randomised controlled trials indicate that NPPV can significantly reduce mortality as well as the need for endotracheal intubation rate, the number of days spent in the intensive care unit without increasing the risk of having a heart attack during or after treatment. We identified fewer adverse events with NPPV use (in particular progressive respiratory distress and neurological failure [coma]) when compared with standard medical care. In our comparison of CPAP and bilevel NPPV, CPAP may be considered the first option in selection of NPPV due to more robust evidence for its effectiveness and safety and lower cost compared with bilevel NPPV. The evidence to date on the potential benefit of NPPV in reducing mortality is entirely derived from small-trials and further large-scale trials are needed.

Authors' conclusions: 

NPPV in addition to standard medical care is an effective and safe intervention for the treatment of adult patients with acute cardiogenic pulmonary oedema. The evidence to date on the potential benefit of NPPV in reducing mortality is entirely derived from small-trials and further large-scale trials are needed.

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Background: 

This is an update of a systematic review previously published in 2008 about non-invasive positive pressure ventilation (NPPV). NPPV has been widely used to alleviate signs and symptoms of respiratory distress due to cardiogenic pulmonary oedema. NPPV prevents alveolar collapse and helps redistribute intra-alveolar fluid, improving pulmonary compliance and reducing the pressure of breathing.

Objectives: 

To determine the effectiveness and safety of NPPV in the treatment of adult patients with cardiogenic pulmonary oedema in its acute stage.

Search strategy: 

We searched the following databases on 20 April 2011: CENTRAL and DARE, (The Cochrane Library, Issue 2 of 4, 2011); MEDLINE (Ovid, 1950 to April 2011); EMBASE (Ovid, 1980 to April 2011); CINAHL (1982 to April 2011); and LILACS (1982 to April 2011). We also reviewed reference lists of included studies and contacted experts and equipment manufacturers. We did not apply language restrictions.

Selection criteria: 

We selected blinded or unblinded randomised or quasi-randomised clinical trials, reporting on adult patients with acute or acute-on-chronic cardiogenic pulmonary oedema and where NPPV (continuous positive airway pressure (CPAP) or bilevel NPPV) plus standard medical care was compared with standard medical care alone.

Data collection and analysis: 

Two authors independently selected articles and abstracted data using a standardised data collection form. We evaluated study quality with emphasis on allocation concealment, sequence generation allocation, losses to follow-up, outcome assessors, selective outcome reporting and adherence to the intention-to-treat principle.

Main results: 

We included 32 studies (2916 participants), of generally low or uncertain risk of bias. Compared with standard medical care, NPPV significantly reduced hospital mortality (RR 0.66, 95% CI 0.48 to 0.89) and endotracheal intubation (RR 0.52, 95% CI 0.36 to 0.75). We found no difference in hospital length of stay with NPPV; however, intensive care unit stay was reduced by 1 day (WMD -0.89 days, 95% CI -1.33 to -0.45). Compared with standard medical care, we did not observe significant increases in the incidence of acute myocardial infarction with NPPV during its application (RR 1.24, 95% CI 0.79 to 1.95) or after (RR 0.70, 95% CI 0.11 to 4.26). We identified fewer adverse events with NPPV use (in particular progressive respiratory distress and neurological failure (coma)) when compared with standard medical care.

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