Noninvasive Ventilation in Acute Cardiogenic Pulmonary Edema
Noninvasive ventilation (NIV) is commonly used to treat patients with acute cardiogenic pulmonary edema (ACPE), but the findings of a recent large clinical trial suggest that NIV may be less effective for ACPE than previously thought. The purpose f this trial was to provide an estimate of the effect of NIV on clinical outcomes in patients with ACPE that incorporates recent trial evidence and explore ways to interpret that evidence in the context of preceding evidence that favors NIV.
The data was extracted from PubMed and EMBASE from 1966 to December 2009, Cochrane Central Register of Controlled Trials and conference proceedings through December 2009, and reference lists, without language restriction. The authors selected randomized trials that compared continuous positive airway pressure [CPAP] and bilevel ventilation [BiPAP] with standard therapy or each other.
The authors found, compared with standard therapy, CPAP reduced mortality (relative risk [RR], 0.64 [95% CI, 0.44 to 0.92]) and need for intubation (RR, 0.44 [CI, 0.32 to 0.60]) but not incidence of new MI (RR, 1.07 [CI, 0.84 to 1.37]). The effect was more prominent in trials in which myocardial ischemia or infarction caused ACPE in higher proportions of patients. BiPAP reduced the need for intubation (RR, 0.54 [CI, 0.33 to 0.86]) but did not reduce mortality or new MI. No differences were detected between CPAP and BiPAP on any clinical outcomes for which they were directly compared.
Weng coworkers concluded that although a recent large trial contradicts results from previous studies, the evidence in aggregate still supports the use of NIV for patients with ACPE. Continuous positive airway pressure reduces mortality more in patients with ACPE secondary to acute myocardial ischemia or infarction.
REFERENCE:
Meta-analysis: Noninvasive Ventilation in Acute Cardiogenic Pulmonary Edema. Cui-Lian Weng, Yun-Tao Zhao, Qing-Hua Liu, Chang-Jun Fu, Feng Sun, Yan-Liang Ma, Yan-Wen Chen, and Quan-Ying He Ann Intern Med May 4, 2010 152:590-600.
