Noninvasive positive pressure ventilation Effect on mortality in acute cardiogenic pulmonary edema: a pragmatic meta‑analysis

Abstract

Noninvasive positive pressure ventilation 349 INTROduCTION Acute cardiogenic pulmonary edema (ACPE) can be caused by a variety of insults including, among others, dietary indiscretion, medication non-compliance, hypertensive crisis, arrhythmias, acute coronary syndromes and valvular lesions. A variety of modalities exist to treat ACPE such as standard medical care including venodilators, after load reduction, inotropic medications and diuretics; insult specific modes like rate controlling agents in tachyarrhythmia; noninvasive positive pressure ventilation modes (NPPV) including continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP); and finally, invasive ventilation/intubation. Several recent meta-analyses (MAs) concluded that NPPV provided a significant mortality benefit in patients with ACPE. 1-5 However, the 3CPO (Three Interventions in Cardiogenic Pulmonary Oedema) trial published in 2008, the largest randomized controlled trial (RCT) of its kind (n = 1069), found no significant mortality benefit from this inter vention. 6 This disagreement presents clinical concern-a physio logically sensible and widely used method of immediate preload, shunt, work of breathing and after load reduction in ACPE is now questioned regarding its effectiveness. This analysis integrates the 3CPO trial mortality data into recent MAs, and presents a modified prediction of the effect on mortality of NPPV

Non-invasive pressure support ventilation and CPAP in cardiogenic pulmonary edema: a multicenter randomized study in the emergency department

“…We believe that to date, we cannot conclude definitively that there is no difference between CPAP and NIPSV in terms of death and intubation rates. In the most recent meta-analysis by Potts, which included the 3CPO trial, it was shown that non-invasive ventilation was superior to conventional treatment, but no comparison was done between NIPSV and CPAP [23]. Important methodological limitations characterize many of the studies conducted in this issue, including small sample size, patient selection, and few observed events which restrict the generalizability of the results to all patients with CPE.…”

Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure

“…However, interpretation of the results is limited by the high crossover rate (56 out of 367 patients (15%) in the oxygen group crossed over to bilevel NIV). Subsequently, five systematic reviews [44][45][46][47][48] that have incorporated the data from GRAY et al [43], as well as other new trials, have been published. They consistently conclude that: 1) NIV decreases the need for intubation, 2) NIV is associated with a reduction in hospital mortality, 3) NIV is not associated with increased myocardial infarction (a concern raised by the first study comparing NIV and CPAP [49]), and 4) CPAP and NIV have similar effects on these outcomes.…”

Effectiveness of Noninvasive Positive Pressure Ventilation in the Management of Acute Respiratory Failure

“…It has been shown to be beneficial for a variety of clinical conditions. Previous studies have demonstrated the efficacy of NPPV in acute exacerbation of chronic obstructive pulmonary disease (COPD) [7,8] , acute cardiogenic pulmonary oedema [9,10] , hypoxaemic respiratory failure [11] and as an adjunct to weaning patients [12,13] .…”