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Evidence summaries

Positive Pressure Airway Support for Cardiogenic Pulmonary Oedema

Non-invasive positive pressure ventilation (NPPV), including continuous positive airway pressure (CPAP) and bilevel NPPV reduces hospital mortality and endotracheal intubation rate in patients with acute cardiogenic pulmonary oedema as compared to standard medical care. Level of evidence: "A"

Summary

A Cochrane review [Abstract] 1 included 24 studies with a total of 2 664 adult participants with respiratory distress due to acute cardiogenic pulmonary oedema (ACPE), not requiring immediate mechanical ventilation. Non-invasive positive pressure ventilation (NPPV), including continuous positive airway pressure (CPAP) and bilevel NPPV, was compared with standard medical care. NPPV significantly reduced hospital mortality and endotracheal intubation with numbers needed to treat of 17 (12 to 32) and 13 (11 to 18), respectively (table T1). There was no difference in hospital length of stay between NPPV and standard care, and adverse events were generally similar between NPPV and standard medical care groups.

Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary oedema compared with standard medical care.

OutcomeRelative effect (95% CI)Assumed risk - Usual careCorresponding risk - NPPV*Participants (studies)
Hospital mortalityRR 0.65 (0.51 to 0.82)176 per 1000114 per 1000 (90 to 144)2 484 (21 studies)
Endotracheal intubation rateRR 0.49 (0.38 to 0.62)154 per 100075 per 1000 (58 to 95)2 449 (20 studies)
Acute myocardial infarctionRR 1.03 (0.91 to 1.16)421 per 1000433 per 1000 (383 to 488)1 313 (5 studies)
Hospital length of stay The mean hospital length of stay was 9.65 daysMD 0.31 days lower(1.23 lower to 0.61 higher)**1 714 (11 studies)
* NPPV = non-invasive positive pressure ventilation (CPAP and bilevel NPPV); ** statistical heterogeneity, I2 =55%
Subgroup analysis by NPPV type identified no significant difference between CPAP and bilevel NPPV subgroups in hospital mortality or endotrachel intubation rates. Both NPPV forms reduced hospital mortality and endotracheal intubation rates compared to standard medical care (table T2 and T3).

Hospital mortality

ComparisonRelative effect (95% CI)Participants (studies)
CPAP versus standard careRR 0.65 (0.48 to 0.88)1 454 (16 studies)
Bilevel NPPV versus standard careRR 0.72 (0.53 to 0.98)1 030 (11 studies)
NPPV = non-invasive positive pressure ventilation
Endotracheal intubation rate
ComparisonRelative effect (95% CI)Participants (studies)
CPAP versus standard careRR 0.46 (0.34 to 0.62)1 413 (15 studies)
Bilevel NPPV versus standard careRR 0.50 (0.31 to 0.81)1 036 (11 studies)
NPPV = non-invasive positive pressure ventilation
References
Berbenetz N, Wang Y, Brown J et al. Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary oedema. Cochrane Database Syst Rev 2019;(4):CD005351. [PubMed]

Primary/Secondary Keywords