NIPPV for acute cardiogenic pulmonary oedema
Date First Published:
February 22, 2001
Last Updated:
May 6, 2003
Report by:
Rupert Jackson, Specialist Registrar in Emergency Medicine (Manchester Royal Infirmary)
Search checked by:
Steve Jones, Manchester Royal Infirmary
Three-Part Question:
In [patients with acute LVF] is [NIPPV better than alternative treatment strategies] 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 diminshed 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 positive pressure ventilation (NIPPV).
Search Strategy:
Medline 1966-08/01 using OVID interface.
Search Details:
[exp pulmonary edema/ or "pulmonary edema".mp or exp ventricular dsyfunction, left/ or exp heart failure, congestive/ or exp myocardial infarction/ or "Left ventricular failure".mp or "lvf".mp] AND [exp positive-pressure respiration/ or exp intermittent positive-pressure ventilation/ or exp respiration, artificial/ or "non-invasive ventilation".mp or "bilevel".mp or "BiPAP".mp or "pressure support".mp] LIMIT to (human and english language) AND maximally sensitive RCT filter.
Outcome:
208 papers were found, of which 4 randomised controlled trials directly addressed the three part question.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Randomized, prospective trial of bilevel versus continuous positive airway pressure in acute pulmonary edema. Mehta S, Jay GD, Woolard RH, et al. 1997, USA | 27 patients with ACPO NIPPV vs CPAP |
Prospective randomised controlled trial | Clinical variables | BP and PaCO2 lower in NIPPV group (p<0.05) | Small numbers Study stopped early due to MI differences. NIPPV had more chest pain at baseline |
| Incidence of myocardial infarction | 10/14 in NIPPV group vs 4/13 with CPAP (p=0.05) | ||||
| Length of ICU/hospital stay, intubation rates, mortality | N/S differences between groups | ||||
| High-dose intravenous isosorbide-dinitrate is safer and better than Bi-PAP ventilation combined with conventional treatment for severe pulmonary edema. Sharon A, Shpirer I, Kaluski E, et al. 2000, Israel | 40 patients with ACPO NIPPV and low dose nitrates vs high dose nitrates alone |
Prospective randomised controlled trial | Mortality | 2/20 in NIPPV group vs 0/20 (N/S) | No power calculation Study stopped early due to differences in rate of intubation Pre-hospital setting |
| Intubation rate | 16/20 in NIPPV group vs 2/20 (p=0.0004) | ||||
| Incidence of myocardial infarction | 11/20 in NIPPV group vs 2/20 (p=0.006) | ||||
| SaO2, pulse and respiratory rates | Improvement significantly slower with NIPPV | ||||
| Non-invasive pressure support ventilation versus conventional oxygen therapy in acute cardiogenic pulmonary oedema: a randomised trial. Masip J, Betbese AJ, Paez J, et al. 2000, Spain | 40 patients with ACPO NIPPV vs O2 |
PRCT | Mortality | Control 2/18<br>Intervention 0/18 | Not analysed on basis of intention to treat Small numbers with likely effect of underpowered study |
| Intubation | Control 6/18<br>Intervention 1/19<br>(P=0.04) | ||||
| Hospital stay | No significant difference between groups | ||||
| Oxygen therapy, continuous positive airway pressure, or non-invasive bilevel positive pressure ventilation in the treatment of acute cardiogenic pulmonary edema. Park M, Lorenzi-Filho G, Feltrim MI, et al. 2001, Brazil | 26 patients with ACPO O2 vs BiPAP vs CPAP |
PRCT | Clinical variables (e.g. RR,HR etc.) | No difference at 60 mins | Small numbers No power calculation No clear randomisation |
| Intubation | O2 – 4/10<br>CPAP – 3/9<br>BiPAP – 0/7 | ||||
| Death | O2 – 0<br>CPAP – 1 (day 3)<br>BiPAP - 0 |
Author Commentary:
This group of trials compared NIPPV with different alternative treatments; oxygen, continuous positive airways pressure (CPAP) or high dose medical therapy. One study showed a benefit in the reduction of intubation rates when NIPPV is compared to oxygen alone, but others have reported evidence of harm with an increased incidence of myocardial infarction in the NIPPV groups. CPAP has already been shown to be of benefit in this patient group (5).
Bottom Line:
The evidence for the use of NIPPV in acute pulmonary oedema is moot. At present CPAP is the safer proven option.
References:
- Mehta S, Jay GD, Woolard RH, et al.. Randomized, prospective trial of bilevel versus continuous positive airway pressure in acute pulmonary edema.
- Sharon A, Shpirer I, Kaluski E, et al.. High-dose intravenous isosorbide-dinitrate is safer and better than Bi-PAP ventilation combined with conventional treatment for severe pulmonary edema.
- Masip J, Betbese AJ, Paez J, et al.. Non-invasive pressure support ventilation versus conventional oxygen therapy in acute cardiogenic pulmonary oedema: a randomised trial.
- Park M, Lorenzi-Filho G, Feltrim MI, et al.. Oxygen therapy, continuous positive airway pressure, or non-invasive bilevel positive pressure ventilation in the treatment of acute cardiogenic pulmonary edema.