Review Article
Noninvasive Ventilation in Acute Cardiogenic Pulmonary Edema: A Meta-Analysis of Randomized Controlled Trials

https://doi.org/10.1016/j.cardfail.2011.05.010Get rights and content

Abstract

Background

The evidence of individual studies in acute cardiogenic pulmonary edema (ACPE) supporting noninvasive ventilation (NIV) is still inconclusive, particularly regarding noninvasive positive pressure ventilation (NIPPV).

Methods

We carried out a meta-analysis. We searched in the Embase, Medline, Cinahl, Dare, Coch, Central, and CNKI databases and congress abstracts for trials comparing continuous positive airway pressure (CPAP) or NIPPV with standard therapy (ST). To assess treatment effects, we carried out direct comparison using a random effects model and adjusted indirect comparison.

Results

At total of 34 studies (3,041 patients) were included. In direct comparisons, both CPAP and NIPPV reduced the risk of death (relative risk [RR] 0.64, 95% CI 0.44–0.93; RR 0.80, 95% CI 0.58–1.10; respectively) compared with ST, although only CPAP had a significant effect. There were no significant differences between NIPPV and CPAP. Pooled results of direct and adjusted indirect comparisons showed that compared with ST, both CPAP and NIPPV significantly reduced mortality (RR 0.63, 95% CI 0.44–0.89; RR 0.73, 95% CI 0.55–0.97; respectively).

Conclusions

Our findings suggest that among ACPE patients, NIV delivered through either NIPPV or CPAP reduced mortality.

Section snippets

Inclusion and Exclusion Criteria

The studies had to meet the following inclusion criteria: be randomized and controlled, compare CPAP or NIPPV with either standard therapy (ST) or each other, include adult patients with ACPE, and have the outcome data available. One study8 comparing CPAP with proportional assist ventilation was also included, because this ventilatory modality has several features of NIPPV. Only published studies were included.

Search Strategy

We conducted an electronic search to retrieve from Embase, Medline, Cinahl, Dare,

Results

We identified 524 reports of studies, of which 118 were duplicates, leaving 406 potentially relevant reports. After title and abstract assessment, 364 reports were excluded because it was evident that the publications were from nonrandomized studies or did not include either the target population or the intervention of interest. We retrieved 42 full text reports for further evaluation, and 8 were finally excluded7 (Fig. 1; also see Supplemental References, available with the online version of

Discussion

The present systematic review suggests that either CPAP or NIPPV reduce in-hospital mortality among ACPE patients. While confirming data suggesting that either form of NIV reduces the need of endotracheal intubation, this meta-analysis provides new data on mortality and shows that NIPPV is associated with more rapid and better oxygenation than CPAP.

This analysis extends earlier findings on the role of NIV among ACPE patients. The present study is the first to demonstrate that NIPPV is

Disclosures

None.

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