CPAP in acute left ventricular failure
Date First Published:
September 28, 2000
Last Updated:
December 6, 2000
Report by:
Rupert Jackson, Specialist Registrar (MRI)
Search checked by:
Simon Carley, MRI
Three-Part Question:
[In patients with acute LVF] is [CPAP better than O2 via normal mask] at [avoiding intubation and improving mortality]?
Clinical Scenario:
A 76 year old male is brought in to A&E in a collapsed state. He has a history of ischaemic heart disease. He is agitated, tachypnoeic and sweating profusely. His neck veins are distended and there are widespread coarse crepitations in his chest. He has a diminished oxygen saturation. You make a clinical diagnosis of acute cardiogenic pulmonary oedema. In addition to vasodilator treatment and opiates, you wonder whether you should administer non-invasive continuous positive airways pressure (CPAP).
Search Strategy:
Medline 1966-09/00 using the OVID interface.
Search Details:
([exp pulmonary edema OR pulmonary oedema.mp OR exp ventricular dysfunction, left OR exp heart failure, congestive OR exp myocardial infarction OR left ventricular failure.mp OR LVF.mp) AND (exp positive-pressure respiration OR CPAP.mp OR continuous positive airway pressure$.mp OR PEEP.mp OR positive end expiratory pressure$.mp] AND maximally sensitive randomised controlled trial filter) LIMIT to human and english language
Outcome:
114 papers were found of which 109 were either irrelevant or of insufficient quality for inclusion. The remaining 5 papers are shown in the table.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Continuous positive airway pressure by face mask in acute cardiogenic pulmonary edema Rasanen J, Heikkila J, Downs J,et al. 1985, Finland | 40 patients with acute cardiogenic pulmonary oedema. RR > 25 and PaO2 < 200 mm Hg CPAP (20) v control (20) |
PRCT | Need for intubation | 6/20 v 12/20 (NS) | Small numbers Unblinded |
| Hospital mortality | 17/20 v 14/20 deaths in hospital (NS) | ||||
| Treatment of severe cardiogenic pulmonary edema with continuous positive airway pressure delivered by face mask. Bersten AD, Holt AW, Vedig AE, et al. 1991, Australia | 39 patients with acute cardiogenic pulmonary oedema. PaO2 <70 mm Hg and PaCO2 >45 mm Hg CPAP (19) v control (20) |
PRCT | Need for intubation | 0/19 v 7/20 (p<0.005) | Small numbers Unblinded Randomisation not concealed |
| Hospital mortality | 2/19 v 4/20 (NS) | ||||
| The efficacy of early continuous positive airway pressure therapy in patients with acute cardiogenic pulmonary edema. Lin M, Chiang HT. 1991, Taiwan | 55 patients with acute cardiogenic pulmonary oedema. RR>22 CPAP (25) v control (30) |
PRCT | Need for intubation | 7/25 v 17/30 (p<0.05) | |
| Hospital mortality | 2/25 v 4/30 (NS) | ||||
| Shunt size | Significantly improved in CPAP group | ||||
| PaO2 | Significantly improved in CPAP group | ||||
| Reappraisal of continuous positive airway pressure therapy in acute cardiogenic pulmonary edema. Short-term results and long-term follow-up. Lin M, Yang YF, Chiang HT, et al. 1991, Taiwan | 100 patients with a clinical diagnosis of acute cardiogenic pulmonary oedema CPAP (50) v control (50) |
PRCT | Need for intubation | 8/50 v 18/50 (P<0.01) | Unblinded |
| Hospital mortality | 4/50 v 6/50 (NS) | ||||
| Effect of nasal continuous positive airway pressure on pulmonary edema complicating acute myocardial infarction. Takeda S, Nejima J, Takano T, et al. 1998, Japan | 22 patients with acute cardiogenic pulmonary oedema. PaO2 <80 mm Hg CPAP (11) v control (11) |
PRCT | Need for intubation | 2/11 v 8/11 (P=0.03) | Small numbers Unblinded |
| hospital mortality | 1/11 v 7/11 (P=0.02) |
Author Commentary:
All of these trials have shown significant reductions in the need to intubate patients in acute pulmonary oedema. In these small trials a reduction in mortality could not be seen. The numbers in the trials are not large and there is not yet absolute evidence of benefit from CPAP. A large, well-designed PRCT may provide this. In the meantime it would appear that patients with severe LVF will benefit from CPAP.
Bottom Line:
Patients presenting with severe acute pulmonary oedema should be treated with continuous positive airway pressure (CPAP).
References:
- Rasanen J, Heikkila J, Downs J,et al.. Continuous positive airway pressure by face mask in acute cardiogenic pulmonary edema
- Bersten AD, Holt AW, Vedig AE, et al.. Treatment of severe cardiogenic pulmonary edema with continuous positive airway pressure delivered by face mask.
- Lin M, Chiang HT.. The efficacy of early continuous positive airway pressure therapy in patients with acute cardiogenic pulmonary edema.
- Lin M, Yang YF, Chiang HT, et al.. Reappraisal of continuous positive airway pressure therapy in acute cardiogenic pulmonary edema. Short-term results and long-term follow-up.
- Takeda S, Nejima J, Takano T, et al.. Effect of nasal continuous positive airway pressure on pulmonary edema complicating acute myocardial infarction.