Efficacy and safety of non-invasive ventilation in the treatment of acute cardiogenic pulmonary edema--a systematic review and meta-analysis

Abstract

Introduction: Continuous positive airway pressure ventilation (CPAP) and non-invasive positive pressure ventilation (NPPV) are accepted treatments in acute cardiogenic pulmonary edema (ACPE). However, it remains unclear whether NPPV is better than CPAP in reducing the need for endotracheal intubation (NETI) rates, mortality and other adverse events. Our aim was to review the evidence about the efficacy and safety of these two methods in ACPE management.

Methods: We conducted a systematic review and meta-analysis of randomized controlled trials on the effect of CPAP and/or NIPV in the treatment of ACPE, considering the outcomes NETI, mortality and incidence of acute myocardial infarction (AMI). We searched six electronic databases up to May 2005 without language restrictions, reviewed references of relevant articles, hand searched conference proceedings and contacted experts.

Results: Of 790 articles identified, 17 were included. In a pooled analysis, 10 studies of CPAP compared to standard medical therapy (SMT) showed a significant 22% absolute risk reduction (ARR) in NETI (95% confidence interval (CI), -34% to -10%) and 13% in mortality (95%CI, -22% to -5%). Six studies of NPPV compared to SMT showed an 18% ARR in NETI (95%CI, -32% to -4%) and 7% in mortality (95%CI, -14% to 0%). Seven studies of NPPV compared to CPAP showed a non-significant 3% ARR in NETI (95%CI, -4% to 9%) and 2% in mortality (95%CI, -6% to 10%). None of these methods increased AMI risk. In a subgroup analysis, NPPV did not lead to better outcomes than CPAP in studies including more hypercapnic patients.

Conclusion: Robust evidence now supports the use of CPAP and NPPV in ACPE. Both techniques decrease NETI and mortality compared to SMT and none shows increased AMI risk. CPAP should be considered a first line intervention as NPPV did not show a better efficacy, even in patients with more severe conditions, and CPAP is cheaper and easier to implement in clinical practice.

Figure 1

Flow chart of the study selection process. ACPO, acute cardiogenic pulmonary edema; ARF = acute respiratory failure; CPAP, continuous positive airway pressure ventilation; ETI, endotracheal intubation; NPPV, non-invasive positive pressure ventilation; MT, medical therapy.

Figure 2

Results and pooled analysis of absolute risk differences (RDs) for the outcomes (a) need for endotracheal intubation, (b) mortality and (c) acute myocardial infarction in trials comparing continuous positive airway pressure ventilation (CPAP) versus medical therapy in acute cardiogenic pulmonary edema patients.

Figure 3

Results and pooled analysis of absolute risk differences (RDs) for the outcomes (a) need for endotracheal intubation, (b) mortality and (c) acute myocardial infarction in trials comparing non-invasive positive pressure ventilation (NPPV) versus medical therapy in acute cardiogenic pulmonary edema patients.

Figure 4

Results and pooled analysis of absolute risk differences (RDs) for the outcomes (a) need for endotracheal intubation, (b) mortality and (c) acute myocardial infarction in trials comparing of continuous positive airway pressure ventilation (CPAP) versus non-invasive positive pressure ventilation (NPPV) in acute cardiogenic pulmonary edema patients patients.

Figure 5

Results and pooled analysis of absolute risk differences (RDs) for the outcomes (a) need for endotracheal intubation, (b) mortality and (c) acute myocardial infarction in trials comparing of continuous positive airway pressure ventilation (CPAP) versus non-invasive positive pressure ventilation (NPPV) in acute cardiogenic pulmonary edema patients patients. Subgroup analysis with stratification by baseline PaCO₂ level.

Figure 6

Funnel plots with effect measures (risk difference (RD)) as a function of its standard error (SE) for the outcome endotracheal intubation in trials comparing (a) continuous positive airway pressure ventilation (CPAP) versus medical therapy; (b) non-invasive positive pressure ventilation (NPPV) versus medical therapy and CPAP versus NPPV.