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

Berbenetz, Nicolas M.; Wang, Yongjun; Brown, J. D.; Godfrey, Charlotte; Ahmad, Mahmud; Vital, Flávia Mr; Lambiase, Pier D.; Banerjee, Amitava; Bakhai, Ameet; Chong, Matthew

doi:10.1002/14651858.cd005351.pub4

Cited by 82 publications

(88 citation statements)

References 89 publications

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“…This Cochrane Review provides relatively good evidence to support this practice, with a number-needed-to-treat of only 13 to prevent the need for intubation and only 17 to save a life. 1 The findings of this review are consistent with recently published clinical practice guidelines by the European Respiratory Society (ERS) and the American Thoracic Society (ATS). 2 Those guidelines, published in 2016, recommend either NIV or CPAP for patients with acute respiratory failure due to cardiogenic pulmonary edema (strong recommendation, moderate certainty of evidence).…”

Section: What Did the Authors Conclude?supporting

confidence: 85%

Should Noninvasive Ventilation Be Used for Treatment of Acute Cardiogenic Pulmonary Edema? A Cochrane Review Summary With Commentary

Hess

2020

Respir Care

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Background Acute cardiogenic pulmonary edema is common in patients with heart disease. It can result in derangements in gas exchange and hemodynamics, leading to hypoxia and death. Standard medical care includes oxygen, diuretics, morphine, and an afterload reducer such as nitroglycerin. Noninvasive ventilation (NIV) and CPAP improve respiratory function by reducing the work of breathing and improving gas exchange. Moreover, the application of positive pressure to the airway increases pleural pressure, which decreases preload and afterload, thereby improving cardiac function. Thus, there is a strong physiologic rationale for the use of NIV or CPAP in the setting of acute cardiogenic pulmonary edema. Few would argue that positive pressure in the form of NIV or CPAP is preferable to endotracheal intubation. A Cochrane review evaluated the evidence to determine whether NIV reduces mortality and the need for endotracheal intubation. 1 The purpose of this commentary is to discuss, with a respiratory care perspective, the published Cochrane Review, "Noninvasive Positive-Pressure Ventilation (CPAP or Bi-Level NPPV) for Cardiogenic Pulmonary Oedema," 1 under the direct supervision of Cochrane Heart Group.

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Section: What Did the Authors Conclude?supporting

confidence: 85%

Should Noninvasive Ventilation Be Used for Treatment of Acute Cardiogenic Pulmonary Edema? A Cochrane Review Summary With Commentary

Hess

2020

Respir Care

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“…Moreover, IV opiates were included in AHF management protocols more often than IV nitroglycerine, which in contrast is one of the mainstay medications well available in EMS units. A vast majority of AHF protocols included respiratory support, which is an essential part of AHF management, and timely NIV may reduce the need for intubation in pulmonary oedema …”

Section: Discussionmentioning

confidence: 99%

“…A vast majority of AHF protocols included respiratory support, which is an essential part of AHF management, and timely NIV may reduce the need for intubation in pulmonary oedema. 28 The diagnosis of both de novo AHF and ADHF is perceived to be easy to moderate. It was found to be significantly more difficult in the dispatching centres.…”

Section: Discussionmentioning

confidence: 99%

Pre‐hospital management protocols and perceived difficulty in diagnosing acute heart failure

Miró

Martín‐Sánchez

et al. 2019

ESC Heart Failure

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Aim To illustrate the pre‐hospital management arsenals and protocols in different EMS units, and to estimate the perceived difficulty of diagnosing suspected acute heart failure (AHF) compared with other common pre‐hospital conditions. Methods and results A multinational survey included 104 emergency medical service (EMS) regions from 18 countries. Diagnostic and therapeutic arsenals related to AHF management were reported for each type of EMS unit. The prevalence and contents of management protocols for common medical conditions treated pre‐hospitally was collected. The perceived difficulty of diagnosing AHF and other medical conditions by emergency medical dispatchers and EMS personnel was interrogated. Ultrasound devices and point‐of‐care testing were available in advanced life support and helicopter EMS units in fewer than 25% of EMS regions. AHF protocols were present in 80.8% of regions. Protocols for ST‐elevation myocardial infarction, chest pain, and dyspnoea were present in 95.2, 80.8, and 76.0% of EMS regions, respectively. Protocolized diagnostic actions for AHF management included 12‐lead electrocardiogram (92.1% of regions), ultrasound examination (16.0%), and point‐of‐care testings for troponin and BNP (6.0 and 3.5%). Therapeutic actions included supplementary oxygen (93.2%), non‐invasive ventilation (80.7%), intravenous furosemide, opiates, nitroglycerine (69.0, 68.6, and 57.0%), and intubation 71.5%. Diagnosing suspected AHF was considered easy to moderate by EMS personnel and moderate to difficult by emergency medical dispatchers (without significant differences between de novo and decompensated heart failure). In both settings, diagnosis of suspected AHF was considered easier than pulmonary embolism and more difficult than ST‐elevation myocardial infarction, asthma, and stroke. Conclusions The prevalence of AHF protocols is rather high but the contents seem to vary. Difficulty of diagnosing suspected AHF seems to be moderate compared with other pre‐hospital conditions.

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“…By contrast, chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) are common comorbidities in VOP and known to benefit from NIV in acute respiratory failure (2,10,11), possibly even in patients with pneumonia (2).…”

Section: Vopmentioning

confidence: 99%

Non-invasive ventilation as the initial ventilatory strategy in very old critically ill patients with community-acquired pneumonia: a multicenter cohort study

Besen

Park

Ranzani

2020

Preprint

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Background The very old patients (≥ 80 years-old, VOP) comprise a subpopulation increasingly admitted to intensive care units (ICUs). Community-acquired pneumonia (CAP) is a common reason for admission and the best strategy of mechanical ventilation for respiratory failure in this scenario is not fully known. Methods Multicenter cohort study of VOPs admitted with CAP in need of invasive (IMV) or noninvasive (NIV) mechanical ventilation to 11 Brazilian ICUs from 2009 through 2012. We used logistic regression models to evaluate the association between ventilator strategy (NIV vs. IMV) and hospital mortality adjusting for confounding factors. We evaluated effect modification with interaction terms in pre-specified sub-groups. Results Of 369 VOPs admitted for CAP with respiratory failure, 232 (63%) received NIV and 137 (37%) received IMV as initial ventilatory strategy. IMV patients were sicker at ICU admission (median SOFA 8 vs. 4, p < 0.001). Hospital mortality was 114/232 (49%) for NIV and 90/137 (66%) for IMV. For the comparison NIV vs. IMV (reference), the crude odds ratio (OR) was 0.50 (95% CI, 0.33–0.78, p=0.002). This association was largely confounded by antecedent characteristics and non-respiratory SOFA (adjOR = 0.70, 95% CI, 0.41–1.20, p=0.196). The fully adjusted model, including Pao2/Fio2 ratio, pH and Paco2, yielded an adjOR of 0.81 (95% CI, 0.46–1.41, p=0.452). There was no strong evidence of effect modification among relevant subgroups, such as Pao2/Fio2 ratio ≤ 150 (p = 0.30), acute respiratory acidosis (p = 0.42) and non-respiratory SOFA ≥ 4 (p = 0.53). Conclusions NIV was not associated with lower hospital mortality when compared to IMV in critically ill VOP admitted with CAP, but there was no strong signal of harm from its use. The main confounders of this association were both the severity of respiratory dysfunction and of extra-respiratory organ failures.

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

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

Cited by 82 publications

References 89 publications

Should Noninvasive Ventilation Be Used for Treatment of Acute Cardiogenic Pulmonary Edema? A Cochrane Review Summary With Commentary

Should Noninvasive Ventilation Be Used for Treatment of Acute Cardiogenic Pulmonary Edema? A Cochrane Review Summary With Commentary

Pre‐hospital management protocols and perceived difficulty in diagnosing acute heart failure

Non-invasive ventilation as the initial ventilatory strategy in very old critically ill patients with community-acquired pneumonia: a multicenter cohort study

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