Cardiology/original researchThe Use of Noninvasive Ventilation in Emergency Department Patients With Acute Cardiogenic Pulmonary Edema: A Systematic Review
Introduction
Acute cardiogenic pulmonary edema is a common cause of respiratory distress in patients presenting to the emergency department (ED). Patients with less severe symptoms of acute heart failure may respond to conventional treatment with oxygen, diuretics, and vasodilators. However, a subset of patients with respiratory compromise will require endotracheal intubation and mechanical ventilation. Unfortunately, this therapy has been associated with significant morbidity, such as nosocomial pulmonary infection, increased need for sedation (and thus longer duration of ventilation), and upper airway complications of endotracheal tube placement.1 As a result, there has been considerable interest in developing less invasive alternatives that can decrease the need for intubation.
Two noninvasive ventilation strategies have been studied in the treatment of acute cardiogenic pulmonary edema. Continuous positive airway pressure is a modality that maintains a constant positive pressure during inspiration and expiration and has been shown to have several benefits. Continuous positive airway pressure decreases the work of breathing2 and left ventricular afterload while maintaining cardiac index.3 Noninvasive positive pressure ventilation (or bilevel positive airway pressure [BiPAP]), which provides inspiratory pressure support coupled with positive end-expiratory pressure, theoretically provides the same benefits of continuous positive airway pressure, as well as inspiratory assistance to further decrease the work of breathing.4 Both treatment modalities are delivered through a tight-fitting facial or nasal mask.
Several small randomized clinical trials in patients with acute cardiogenic pulmonary edema have demonstrated a reduced need for intubation and mechanical ventilation with continuous positive airway pressure. These studies lacked sufficient power to detect a decrease in mortality.5, 6, 7 A systematic review and meta-analysis performed in 1998 suggested an absolute risk difference of 26% in the need for intubation with continuous positive airway pressure compared to standard care alone and a trend toward decreased hospital mortality.8 Of the 3 trials included, one included patients that were not clearly identified and treated in the ED.7
At the time of the Pang et al8 review, only 1 trial of noninvasive positive pressure ventilation in acute cardiogenic pulmonary edema had been published. That study demonstrated greater respiratory and hemodynamic improvement in the noninvasive positive pressure ventilation group compared with continuous positive airway pressure, but both continuous positive airway pressure and noninvasive positive pressure ventilation had similar rates of intubation and hospital mortality.4 However, there was an increased incidence of myocardial infarction reported in the noninvasive positive pressure ventilation group.
Since 1998, there have been a number of additional small randomized trials comparing noninvasive ventilation in addition to standard medical therapy versus standard medical therapy alone, or noninvasive positive pressure ventilation was compared to continuous positive airway pressure (both in addition to standard medical therapy) in an attempt to clarify the role of noninvasive ventilation in cardiogenic pulmonary edema.9, 10, 11, 12, 13, 14, 15, 16, 17, 18 Two of these trials suggested a decreased rate of intubation with noninvasive ventilation compared with standard medical therapy,9, 11 and one suggested a decreased rate of hospital mortality in the noninvasive ventilation group when compared with standard medical therapy.11 The remainder of the studies suggests that noninvasive ventilation had no effect on rates of hospital mortality or intubation. To date, there have been no systematic reviews that have focused solely on the use of noninvasive ventilation in ED patients with acute cardiogenic pulmonary edema.
The purpose of this systematic review was to critically evaluate the body of evidence on noninvasive ventilation in patients who had acute cardiogenic pulmonary edema and presented to the ED. Four interventions were assessed: (1) noninvasive ventilation (continuous positive airway pressure or noninvasive positive pressure ventilation) compared with standard medical therapy alone; (2) a comparison of continuous positive airway pressure and noninvasive positive pressure ventilation; (3) continuous positive airway pressure compared with standard medical therapy alone; and (4) noninvasive positive pressure ventilation compared with standard medical therapy alone. The primary and secondary outcome measurements (metameters) were hospital mortality and the rate of intubation, respectively.
Section snippets
Study Design
In reporting the results of this systematic review, the authors have followed the recommended guidelines from the Quality of Reporting of Meta-Analysis (QUORUM) Statement.19
A comprehensive literature search of MEDLINE, EMBASE, and the Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, Clinical Trials Register) from January 1980 to July 2005 was performed. The key words used were “congestive heart failure,” “heart failure,” “pulmonary edema,”
Characteristics of Study Subjects
The initial search strategy identified 22,658 possible publications relevant to this meta-analysis (Figure 1). After applying the initial exclusion criteria to this search, a total of 442 trials were reviewed in more detail for inclusion. The majority of these studies (n=415) were excluded because they did not involve the management of acute cardiogenic pulmonary edema (n=112), involved patients with respiratory failure caused by multiple conditions (n=111), did not involve a randomization
Limitations
This analysis was based on aggregate data from all the individual studies. In this meta-analysis, the similarity of inclusion criteria and intervention protocols between studies suggests comparable patient populations and was supported by the lack of significant heterogeneity. Although baseline characteristics were similar between treatment groups, the inability to adjust statistically for differences in other factors beyond treatment group assignment could have influenced the hospital
Discussion
To our knowledge, this is the first meta-analysis of noninvasive ventilation in ED patients with acute cardiogenic pulmonary edema. The results of this meta-analysis suggest that a strategy of noninvasive ventilation plus standard medical therapy significantly reduces hospital mortality and need for endotracheal intubation when compared with standard medical therapy alone. From this analysis, it can be estimated that early application of noninvasive ventilation in the ED can decrease the
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Supervising editor: Brian H. Rowe, MD, MSc
Author contributions: SC, LM, HW, MB, DS conceived the study and performed the overall literature search and data abstraction. SC and LM performed data analysis. SC, LM, HW, MB, DS, AS contributed to the writing of the manuscript. SC takes responsibility for the paper as a whole.
Funding and support: The authors report this study did not receive any outside funding or support.
Reprints not available from the authors.