Is noninvasive pressure support ventilation as effective and safe as continuous positive airway pressure in cardiogenic pulmonary oedema?

Agarwal R, Aggarwal AN, Gupta D
Correspondence: Dr Ritesh Agarwal, riteshpgi@gmail.com

ABSTRACT
Introduction Noninvasive ventilation (NIV) with continuous positive airway pressure (CPAP) has been shown to decrease endotracheal intubation and mortality in patients with acute cardiogenic pulmonary oedema (ACPE). The Three Interventions in Cardiogenic Pulmonary Oedema showed no advantage of NIV over standard medical therapy. This meta-analysis is an update on the efficacy and safety of two different forms of NIV (noninvasive pressure support ventilation [NIPSV] vs. CPAP) in patients with ACPE.
Methods We searched the MEDLINE and EMBASE databases for randomised clinical trials published from 1980 to 2008 that have compared NIPSV and CPAP in patients with ACPE. We calculated the odds ratio (OR) with 95 percent confidence intervals (CI) and pooled the results using three different statistical models (fixed effects, random effects and exact method).
Results Ten studies (577 and 576 in the CPAP and NIPSV groups, respectively) met our inclusion criteria. NIPSV performed similar to CPAP in decreasing the intubation rates (OR 0.8; 95 percent CI 0.43–1.49), hospital mortality (OR 1.08; 95 percent CI 0.76–1.54) and the occurrence of myocardial infarction (OR 0.8; 95 percent CI 0.36–1.76). The results were similar when pooling the data with any of the three statistical methods and stratifying for the type of pressure therapy (fixed vs. variable) except for myocardial infarction, which was more frequent in the fixed pressure NIPSV arm (OR 5.06; 95 percent CI 1.66–15.44).
Conclusion NIPSV appears to be as safe and efficacious as CPAP, if titrated rather than fixed pressures are employed.

Keywords: acute cardiogenic pulmonary oedema, continuous positive airway pressure, intratracheal intubation, noninvasive pressure support ventilation, noninvasive ventilation, pulmonary oedema, positive-pressure respiration, respiratory insufficiency
Singapore Med J 2009; 50(6): 595-603