Chest
Volume 114, Issue 4, October 1998, Pages 1185-1192
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The Effect of Positive Pressure Airway Support on Mortality and the Need for Intubation in Cardiogenic Pulmonary Edema: A Systematic Review

https://doi.org/10.1378/chest.114.4.1185Get rights and content

Objective

To critically appraise and summarize the trials examining the addition of continuous positive airway pressure (CPAP) or noninvasive positive pressure ventilation (NPPV) to standard therapy on hospital mortality, need for endotracheal intubation, and predischarge left ventricular function in patients admitted to the hospital with cardiogenic pulmonary edema with gas exchange abnormalities.

Data sources

We searched MEDLINE (1983 to June 1997) and bibliographies of all selected articles and review articles. We also reviewed the abstracts from the proceedings of relevant meetings from 1985 to 1997.

Study selection

(1) Population: patients presenting to hospital with cardiogenic pulmonary edema; (2) intervention: one of the following three: (a) the use of CPAP and standard medical therapy vs standard medical therapy alone; (b) the use of NPPV and standard medical therapy vs standard medical therapy alone; and (c) the use of NPPV and standard therapy vs CPAP and standard therapy; (3) outcome: hospital survival, need for endotracheal intubation, or predischarge left ventricular dysfunction; and (4) study design: randomized controlled trial (RCT); if there were fewer than two RCTs, other study designs were included.

Data extraction

Two authors independently extracted data and evaluated the methodologic quality of the studies.

Data synthesis

CPAP was associated with a decrease in need for intubation (risk difference −26%, 95% confidence intervals, −13 to −38%) and a trend to a decrease in hospital mortality (risk difference, −6.6%; +3 to −16%) compared with standard therapy alone. There was insufficient evidence to comment on the effectiveness of NPPV either compared with standard therapy or CPAP and standard therapy. Evidence was also lacking on the potential for either intervention to cause harm.

Conclusions

A modest amount of favorable experimental evidence exists to support the use of CPAP in patients with cardiogenic pulmonary edema. CPAP appears to decrease intubation rates and data suggest a trend toward a decrease in mortality, although the potential for harm has not been excluded. The role of NPPV in this setting requires further study before it can be widely recommended.

Section snippets

Search Strategy

We used a number of search strategies to identify the relevant literature, including computerized literature searches of the National Library of Medicine's MEDLINE from 1983 to June 1997, using the key words pulmonary edema (therapy) and respiratory insufficiency (therapy) separately, with and without positive pressure respiration. These searches were limited to studies on humans and those published in English. Bibliographies of all selected articles and review articles were reviewed for other

Search and Study Selection

A total of 497 potentially relevant articles were identified using the search strategy described. Of these, only three randomized trials fulfilled all four selection criteria for studies comparing CPAP with standard therapy1, 2, 3 (Table 1). Reasons for exclusion of others were: nonrandomized clinical trials (n = 466), alternative study population (patients other than those with cardiogenic pulmonary edema) (n = 436), crossover trial (n = 1), and one study in which the patients may have been

DISCUSSION

From our systematic review of the literature, we conclude that the use of CPAP by face mask in patients with cardiogenic pulmonary edema and respiratory distress may decrease the need for endotracheal intubation. The three randomized controlled trials suggest a trend toward a decrease in hospital mortality in patients treated with CPAP; however, the 95% CI does not allow the exclusion of harm.1, 2, 3 The only study examining the impact of CPAP on left ventricular function found no difference

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    Development of ventilatory support devices, such as continuous positive airway pressure (CPAP) and non-invasive ventilation (NIV), has played a decisive role in the treatment of ARF secondary to CPE. The use of either CPAP2–7 or NIV8–11 has resulted in greater clinical improvements compared with standard medical therapy. Hypercapnia without chronic lung disease has been associated with poor outcomes in patients with CPE,12,13 particularly when PaCO2 is higher than 60 mmHg.13

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Supported by the Richard Ivey Critical Care Trauma Center, London Health Sciences Centre, Victoria Campus, and the Program of Critical Care Medicine, University of Western Ontario, London, ON, Aberdeen Medical School. Dr. Keenan is supported by a Canadian Lung Association/Medical Research Council Fellowship. Dr. Cook is a Career Scientist of the Ontario Ministry of Health

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