Date: October  8 2012

Case Scenario: 55-year-old man arrives via EMS very short of breath, diaphoretic and speaking only one-two word sentences. If you don’t do something soon it will result in “badness“.

Question: Is noninvasive ventilation beneficial for patients with acute cardiogenic pulmonary edema?

Reference: Weng CL, Zhao YT, Liu QH, Fu CJ, Sun F, Ma YL, Chen YW, He QY. Meta-Analysis: Noninvasive Ventilation In Acute Cardiogenic Pulmonary Edema. Ann Intern Med. 2010 May 4;152(9):590-600.

  • Populations: 2887 patients with Acute Cardiogenic Pulmonary Edema (ACPE) from 31 RCTs.
  • Intervention: Continuous positive airway pressure and bilevel ventilation.
  • Control: Standard therapy or each other.
  • Outcome: Mortality, need for intubation, new MI.

Key Results:

  • In Hospital Mortality   N   RR (CI) 
    • CPAP vs Standard Rx  697  0.64 (.44-.92)  
    • BiPAP v Standard Rx  548  0.82 (.58-1.15) 
    • BiPAP v CPAP  728  1.06 (.72-1.57) 
  • Intubation  N  RR (CI)  
    • CPAP vs Standard Rx   764   0.44 (.32-.60)  
    • BiPAP v Standard Rx  579  0.54 (.33-.86)  
    • BiPAP v CPAP   747   1.23 (.72-2.10)  

Authors’ Conclusions: “…the evidence in aggregate still supports the use of NIV for patients with ACPE. Continuous positive airway pressure reduces mortality more in patients with ACPE secondary to acute myocardial ischemia or infarction.”

BEEM Comments: The 3CPO RCT found no difference in mortality and intubation rates between patients with ACPE treated with NIPPV versus standard therapy alone despite recent meta-analyses on the topic. This more recent meta-analysis sought to update these results to verify the clinical implications of the 3CPO trial. In contrast to the C3PO trial, their findings were consistent with prior investigations of reduced mortality and need to intubate without an increase in AMI.

BEEM Bottom Line: NIPPV decreased mortality and the need for intubation in patients that presented to the ED with ACPE

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.