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Meta-Analysis
. 2019 Apr 5;4(4):CD005351.
doi: 10.1002/14651858.CD005351.pub4.

Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary oedema

Nicolas Berbenetz  1 , Yongjun Wang, James Brown, Charlotte Godfrey, Mahmood Ahmad, Flávia Mr Vital, Pier Lambiase, Amitava Banerjee, Ameet Bakhai, Matthew Chong
Affiliations
Meta-Analysis

Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary oedema

Nicolas Berbenetz et al. Cochrane Database Syst Rev. .

Abstract

Background: Non-invasive positive pressure ventilation (NPPV) has been used to treat respiratory distress due to acute cardiogenic pulmonary oedema (ACPE). We performed a systematic review and meta-analysis update on NPPV for adults presenting with ACPE.

Objectives: To evaluate the safety and effectiveness of NPPV compared to standard medical care (SMC) for adults with ACPE. The primary outcome was hospital mortality. Important secondary outcomes were endotracheal intubation, treatment intolerance, hospital and intensive care unit length of stay, rates of acute myocardial infarction, and adverse event rates.

Search methods: We searched CENTRAL (CRS Web, 20 September 2018), MEDLINE (Ovid, 1946 to 19 September 2018), Embase (Ovid, 1974 to 19 September 2018), CINAHL Plus (EBSCO, 1937 to 19 September 2018), LILACS, WHO ICTRP, and clinicaltrials.gov. We also reviewed reference lists of included studies. We applied no language restrictions.

Selection criteria: We included blinded or unblinded randomised controlled trials in adults with ACPE. Participants had to be randomised to NPPV (continuous positive airway pressure (CPAP) or bilevel NPPV) plus standard medical care (SMC) compared with SMC alone.

Data collection and analysis: Two review authors independently screened and selected articles for inclusion. We extracted data with a standardised data collection form. We evaluated the risks of bias of each study using the Cochrane 'Risk of bias' tool. We assessed evidence quality for each outcome using the GRADE recommendations.

Main results: We included 24 studies (2664 participants) of adult participants (older than 18 years of age) with respiratory distress due to ACPE, not requiring immediate mechanical ventilation. People with ACPE presented either to an Emergency Department or were inpatients. ACPE treatment was provided in an intensive care or Emergency Department setting. There was a median follow-up of 13 days for hospital mortality, one day for endotracheal intubation, and three days for acute myocardial infarction. Compared with SMC, NPPV may reduce hospital mortality (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.51 to 0.82; participants = 2484; studies = 21; I2 = 6%; low quality of evidence) with a number needed to treat for an additional beneficial outcome (NNTB) of 17 (NNTB 12 to 32). NPPV probably reduces endotracheal intubation rates (RR 0.49, 95% CI 0.38 to 0.62; participants = 2449; studies = 20; I2 = 0%; moderate quality of evidence) with a NNTB of 13 (NNTB 11 to 18). There is probably little or no difference in acute myocardial infarction (AMI) incidence with NPPV compared to SMC for ACPE (RR 1.03, 95% CI 0.91 to 1.16; participants = 1313; studies = 5; I2 = 0%; moderate quality of evidence). We are uncertain as to whether NPPV increases hospital length of stay (mean difference (MD) -0.31 days, 95% CI -1.23 to 0.61; participants = 1714; studies = 11; I2 = 55%; very low quality of evidence). Adverse events were generally similar between NPPV and SMC groups, but evidence was of low quality.

Authors' conclusions: Our review provides support for continued clinical application of NPPV for ACPE, to improve outcomes such as hospital mortality and intubation rates. NPPV is a safe intervention with similar adverse event rates to SMC alone. Additional research is needed to determine if specific subgroups of people with ACPE have greater benefit of NPPV compared to SMC. Future research should explore the benefit of NPPV for ACPE patients with hypercapnia.

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Conflict of interest statement

Nicolas Berbenetz: none known

Yongjun Wang: none known

James Brown: none known

Charlotte Godfrey: none known

Mahmood Ahmad: none known

Flávia Vital: none known

Pier Lambiase: receives speaker fees and educational grant funding from Boston Scientific, and educational grant funding from Medtronic for work unrelated to the content of this Cochrane review.

Amitava Banerjee: none known

Ameet Bakhai: is employed within the NHS and also advises third sector companies (pharma, device, diagnostics, digital and AI) on trial design, economic models, technology adoption and acts as lecturer for cardiovascular topics. As research director, he also recruits to trials and supports research partnership work for his NHS employer, which attracts commercial research recruitment funding. There are no direct conflicts to the work presented however.

Matthew Chong: none known

Figures

1
1
PRISMA statement flow diagram for 2019 review update.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
4
4
Funnel plot of comparison: 1 NPPV vs SMC, outcome: 1.1 HOSPITAL MORTALITY.
5
5
Funnel plot of comparison: 1 NPPV vs SMC, outcome: 1.8 ETI RATE.
6
6
Funnel plot of comparison: 1 NPPV vs SMC, outcome: 1.17 HOSPITAL LENGTH OF STAY.
1.1
1.1. Analysis
Comparison 1 NPPV vs SMC, Outcome 1 HOSPITAL MORTALITY.
1.2
1.2. Analysis
Comparison 1 NPPV vs SMC, Outcome 2 Hospital mortality ‐ by NPPV.
1.3
1.3. Analysis
Comparison 1 NPPV vs SMC, Outcome 3 Hospital mortality ‐ by location.
1.4
1.4. Analysis
Comparison 1 NPPV vs SMC, Outcome 4 Hospital mortality ‐ by baseline PaCO2.
1.5
1.5. Analysis
Comparison 1 NPPV vs SMC, Outcome 5 Hospital mortality ‐ sensitivity analysis (low risk of bias).
1.6
1.6. Analysis
Comparison 1 NPPV vs SMC, Outcome 6 Hospital mortality ‐ sensitivity analysis (missing data).
1.7
1.7. Analysis
Comparison 1 NPPV vs SMC, Outcome 7 Hospital mortality ‐ sensitivity analysis (fixed‐effect).
1.8
1.8. Analysis
Comparison 1 NPPV vs SMC, Outcome 8 ETI RATE.
1.9
1.9. Analysis
Comparison 1 NPPV vs SMC, Outcome 9 ETI rate ‐ by NPPV.
1.10
1.10. Analysis
Comparison 1 NPPV vs SMC, Outcome 10 ETI rate ‐ by location.
1.11
1.11. Analysis
Comparison 1 NPPV vs SMC, Outcome 11 ETI rate ‐ by baseline PaCO2.
1.12
1.12. Analysis
Comparison 1 NPPV vs SMC, Outcome 12 ETI rate ‐ sensitivity analysis (low risk of bias).
1.13
1.13. Analysis
Comparison 1 NPPV vs SMC, Outcome 13 ETI rate ‐ sensitivity analysis (missing data).
1.14
1.14. Analysis
Comparison 1 NPPV vs SMC, Outcome 14 ETI rate ‐ by face mask type.
1.15
1.15. Analysis
Comparison 1 NPPV vs SMC, Outcome 15 ACUTE MI INCIDENCE.
1.16
1.16. Analysis
Comparison 1 NPPV vs SMC, Outcome 16 Acute MI incidence ‐ by NPPV.
1.17
1.17. Analysis
Comparison 1 NPPV vs SMC, Outcome 17 HOSPITAL LENGTH OF STAY.
1.18
1.18. Analysis
Comparison 1 NPPV vs SMC, Outcome 18 Hospital length of stay ‐ by NPPV.
1.19
1.19. Analysis
Comparison 1 NPPV vs SMC, Outcome 19 Hospital length of stay ‐ by location.
1.20
1.20. Analysis
Comparison 1 NPPV vs SMC, Outcome 20 Hospital length of stay ‐ by baseline PaCO2.
1.21
1.21. Analysis
Comparison 1 NPPV vs SMC, Outcome 21 ICU LENGTH OF STAY.
1.22
1.22. Analysis
Comparison 1 NPPV vs SMC, Outcome 22 SYSTOLIC BP AFTER ONE HOUR.
1.23
1.23. Analysis
Comparison 1 NPPV vs SMC, Outcome 23 Systolic BP after one hour ‐ by NPPV.
1.24
1.24. Analysis
Comparison 1 NPPV vs SMC, Outcome 24 DIASTOLIC BP AFTER ONE HOUR.
1.25
1.25. Analysis
Comparison 1 NPPV vs SMC, Outcome 25 Diastolic BP after one hour ‐ by NPPV.
1.26
1.26. Analysis
Comparison 1 NPPV vs SMC, Outcome 26 MEAN BP AFTER ONE HOUR.
1.27
1.27. Analysis
Comparison 1 NPPV vs SMC, Outcome 27 RESPIRATORY RATE AFTER ONE HOUR.
1.28
1.28. Analysis
Comparison 1 NPPV vs SMC, Outcome 28 Respiratory rate after one hour ‐ by NPPV.
1.29
1.29. Analysis
Comparison 1 NPPV vs SMC, Outcome 29 PaO2 (mmHg) AFTER ONE HOUR.
1.30
1.30. Analysis
Comparison 1 NPPV vs SMC, Outcome 30 PaO2 (mmHg) after one hour ‐ by NPPV.
1.31
1.31. Analysis
Comparison 1 NPPV vs SMC, Outcome 31 ADVERSE EVENTS.
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References to other published versions of this review

Vital 2005
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