Noninvasive ventilation for acute pulmonary edema

January 01, 0001

Noninvasive ventilation for acute pulmonary edema

Noninvasive ventilation (NIV) is commonly used to treat patients with acute cardiogenic pulmonary edema (ACPE), but the findings of a recent large clinical trial suggest that NIV may be less effective for ACPE than previously thought. These Chinese authors performed a meta-analysis to provide an estimate of the effect of NIV on clinical outcomes in patients with ACPE that incorporates recent trial evidence and explore ways to interpret that evidence in the context of preceding evidence that favors NIV. They included randomized trials that compared continuous positive airway pressure and bilevel ventilation with standard therapy or each other.

They found: "Compared with standard therapy, continuous positive airway pressure reduced mortality (RR 0.64) and need for intubation (RR 0.44) but not incidence of new MI (RR 1.07). The effect was more prominent in trials in which myocardial ischemia or infarction caused ACPE in higher proportions of patients (RR 0.92 when 10% of patients had ischemia or MI vs. 0.43 when 50% had ischemia or MI). Bilevel ventilation reduced the need for intubation (RR 0.54) but did not reduce mortality or new MI. No differences were detected between continuous positive airway pressure and bilevel ventilation on any clinical outcomes for which they were directly compared."

The authors concluded: "Although a recent large trial contradicts results from previous studies, the evidence in aggregate still supports the use of NIV for patients with ACPE. Continuous positive airway pressure reduces mortality more in patients with ACPE secondary to acute myocardial ischemia or infarction."

It is always a good idea to look at the evidence in aggregate. Sometimes one large well-designed study is enough to outweigh prior smaller and less vigorous studies.

For the full abstract, click here.

Ann Intern Med 152(9):590-600, 4 May 2010 © 2010 to the American College of Physicians
Meta-analysis: Noninvasive Ventilation in Acute Cardiogenic Pulmonary Edema. Cui-Lian Weng, Yun-Tao Zhao, Qing-Hua Liu, et al.

Category: R. Respiratory. Keywords: pulmonary edema, myocardial infarction, noninvasive ventilation, continuous positive airway pressure, bilevel ventilation, meta-analysis of randomized controlled trials, journal watch.
Synopsis edited by Dr Linda French, Toledo, Ohio. Posted on Global Family Doctor 25 May 2010

Pearls are an independent product of the Cochrane primary care group and are meant for educational use and not to guide clinical care.