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Non-invasive ventilation in patients with acute cardiogenic pulmonary oedema: a meta-analysis
Citation/s: John
V. Peter, et al. Effect of non-invasive positive pressure ventilation (
NIPPV) on mortality in patients with acute cardiogenic pulmonary oedema: a
meta-analysis. Lancet 2006; 367: 1155-63 Three-part Clinical Question: Patients: Patients with cardiogenic pulmonary oedema. Intervention: NIPPV (CPAP and Bi-level) Outcomes: Reduce mortality, need for IPPV, length of hospital stay and what are the associated failure rates plus incidence of new MI. Search Terms: Pulmonary oedema, heart failure, respiratory insufficiency, positive pressure ventilation, continuous positive airway pressure, non-invasive ventilation, non-invasive positive pressure ventilation, nasal ventilation and BIPAP The Review: Data Sources: Cochrane Library, Medline, Embase, Citation Index, hand search, non-English sources, Am. Coll. Of Physicians (ACP) J Club, DARE Study Selection: Randomised trials on acute cardiogenic pulmonary oedema. Comparing standard therapy (oxygen by facemask, diuretics, nitrates and other supportive care) with CPAP or Bi-level NIPPV. Only trials reporting hospital mortality or need for IPPV were included. Trials classified into 3 groups: (i) CPAP versus standard therapy, (ii) bi-level ventilation versus standard therapy and (iii) CPAP versus bi-level ventilation. Data Extraction: The studies were reviewed by two investigators, differences in opinion settled by consensus. They were tested for heterogeneity. The Evidence:
Other results comments: No comment made on mode of delivery of NIPPV. Study sample sizes relatively small. Included studies appear of intermediate quality. No difference in mortality between CPAP and BiPAP. Significant reduction in need for IPPV for both CPAP and BIPAP. No significant difference in hospital stay between treatment groups. Weak evidence of an increase in new MI with Bi-level ventilation. EBM Comments: 1) Do the methods allow accurate testing of the hypothesis? Yes 2) Do the statistical tests correctly test the results to allow differentiation of statistically significant results? Yes 3) Are conclusions valid in light of the results? Yes 4) Did results get omitted, and why? Yes. Studies not randomised or inappropriate endpoints. Descriptive studies. 5) Did they suggest areas of further research? Yes. Role of PEEP/EPAP in relation to increased incidence of MI. Role of BiPAP in hypercapnic patients. 6) Did they make any recommendations based on the results and were they appropriate? Yes. That the British Thoracic Societies recommendations are appropriate: CPAP should be used in patients with cardiogenic pulmonary oedema who still have hypoxia despite the best medical treatment, and reserve the use of bilevel ventilation for patients in whom CPAP is unsuccessful. 7) Is the study relevant to my clinical practice? Yes 8) What level of evidence does this study represent? 1+ (meta-analysis with a low risk of bias) 9) What grade of recommendation can I make on this result alone? A 10) What grade of recommendation can I make when this study is considered along with other available evidence? A 11) Should I change my practice because of these results? Yes. If you are not currently using NIV in the management of cardiogenic pulmonary oedema, you should consider adding it to your medical treatment. 12) Should I audit my current practice because of these results? Yes Appraised by: Brian Digby, SpR in Anaesthesia & Intensive Care, Stirling Royal Infirmary ; 24 April 2006 Email: briandigby@hotmail.com Citation: EBM Critical Appraisals. Scottish Intensive Care Society EBM Group. 2006 & JICS 2006 Vol7(2). Digby B: John V. Peter, et al. Effect of non-invasive positive pressure ventilation ( NIPPV) on mortality in patients with acute cardiogenic pulmonary oedema: a meta-analysis. Lancet 2006; 367: 1155-63 ©SICS EBM 2006 Kill or Update By: May, 2011 Reviewed & Edited by CC & BT. |
