Non-invasive Positive Pressure Ventilation for Acute Cardiogenic Pulmonary Edema and Chronic Obstructive Pulmonary Disease in Prehospital and Emergency Settings

Abstract

Non-invasive ventilation is an important intervention in treating acute respiratory failure caused by acute cardiogenic pulmonary edema (ACPE) and acute exacerbations of chronic obstructive pulmonary disease (COPD). Although there are studies that give evidence on the efficacy and safety of non-invasive ventilation over standard medical care for COPD and cardiogenic pulmonary edema, less are known about the form of non-invasive ventilation, continuous positive airway pressure (CPAP), or bilevel positive airway pressure (BiPAP) as an effective intervention for respiratory failure and its efficacy and safety in prehospital settings. We conducted a systematic review by using PubMed and Google Scholar as databases for collecting studies related to the effectiveness of CPAP and BiPAP for cardiogenic pulmonary edema and COPD; the major outcome studied was reducing rates of endotracheal intubation secondary and tertiary outcomes included mortality reduction and shortening length of hospital stay. The study follows the guidelines of the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) checklist 2009. Sixteen studies were identified, including systematic reviews, randomized control trials, and observational studies. Studies published on or after 2010 in a population greater than 40 years old suffering from acute COPD and cardiogenic pulmonary edema were taken for review. Studies that described other respiratory diseases treated with non-invasive ventilation were excluded. Quality appraisal was done using the Cochrane risk bias tool for randomized control trials, Amstar-2 for systematic reviews, and New Castle Ottawa Tool for observational studies. Five studies compared the effectiveness of CPAP and BiPAP with standard medical care in prehospital and emergency settings. Six studies described prehospital intervention. Both forms of non-invasive ventilation were equally significant and effective. Prehospital use had tremendously reduced intubation rates, with not much variability noticed for mortality and hospital stay. Non-invasive ventilation is an effective measure for respiratory failure secondary to COPD and ACPE. Early out of hospital utilization of CPAP and BiPAP reduces the rate of invasive ventilation and reduces complications due to endotracheal intubation. Endotracheal intubation is associated with a considerable incidence of complications like failed intubation, hypotension, or circulatory arrest, even if the emergency physician is well trained, making these forms of non-invasive ventilation safe and effective interventions in the prehospital settings.

Keywords: bipap; chronic obstructive pulmonary disease; cpap; heart failure; non-invasive ventilation; pulmonary diseases; pulmonary edema.

Figure 1. PRISMA 2009 Flow Diagram

PRISMA - Preferred Reporting Items for Systematic Reviews and Meta-Analysis

Figure 2. Rates of mortality and intubation with CPAP and BiPAP

CPAP - Continuous Positive Airway Pressure, BiPAP - Bilevel Positive Airway Pressure

Figure 3. Rates of intubation and mortality of prehospital CPAP compared with standard medical care alone

NIV - Non-invasive Ventilation, SMC - Standard Medical Care, CPAP - Continuous Positive Airway Pressure

Figure 4. Rates of mortality and intubation with non-invasive ventilation compared to standard medical care alone

NIV - Non-invasive Ventilation, SMC - Standard Medical Care