Introduction
Materials and methods
Study design
Selection criteria
Search strategy
Study quality assessment and data abstraction
General quality criteria |
---|
Sample size (total number of participants) |
Randomization allocation concealment (adequate, inadequate or uncertain) |
Objective selection criteria for participants: |
Yes: if inclusion and exclusion criteria for participants are adequately reported |
No: if selection criteria are not reported |
Blinding: |
Yes: for articles that implemented blinding at any level |
No: for articles reporting not being able to implement blinding of interventions at any level |
Not reported: for articles that did not make any mention of blinding |
Standardization of co-interventions: |
Yes: if there was an attempt to standardize treatment and care besides the assigned interventions |
No: if no attempt to standardize was applied |
Uncertain: if this was not clearly reported |
Intention-to-treat analysis (adequate, inadequate or uncertain) |
Complete follow-up details (yes, no, not reported) |
Outcome definition: |
Adequate: if objective criteria for endotracheal intubation were defined |
Inadequate: if the criteria were not defined |
Uncertain: if application of criteria was unclear |
Specific quality criteria
|
Patient selection criteria (inclusion and exclusion) |
Type of patients (presence of baseline co-morbidity: AMI or chronic obstructive pulmonary disease) |
Description of baseline criteria for severity of illness |
Report of interventions (technical description of CPAP and NPPV methods) |
Report of objective criteria for endotracheal intubation (adequate, inadequate or uncertain) |
Statistical analysis
Results
Search and study selection
Reference | Country and Setting | Sample size | Interventions | Outcomes analyzed | Randomization assignment concealmenta | Objective selection criteriab | Blindingc | Standardization of co-interventionsd | Intention-to-treat analysise | Complete follow-up detailsf | Outcome definitiong |
---|---|---|---|---|---|---|---|---|---|---|---|
Rasanen et al. 1985 [62] | Finland: ED and ICU | 40 | SMT vs CPAP | Meeting criteria for ETI during 3 h follow-up; in-hospital mortality | Adequate | Yes | NR | Yes | Adequate | Yes | Adequate |
Bersten et al. 1991 [63] | Australia: ICU | 39 | SMT vs CPAP | Meeting criteria for ETI during 24 h follow-up; in-hospital mortality | Uncertain | Yes | No | Yes | Uncertain | Yes | Adequate |
Lin et al. 1995 [57] | Taiwan: ICU | 100 | SMT vs CPAP | Meeting criteria for ETI during 6 h follow-up; in-hospital mortality | Uncertain | Yes | NR | Yes | Adequate | Yes | Adequate |
Takeda et al. 1997 [11] | Japan: CU | 30 | SMT vs CPAP | Meeting criteria for ETI during 24 h follow-up; in-hospital mortality | Uncertain | Yes | NR | Yes | Adequate | Yes | Adequate |
Takeda et al. 1998 [12] | Japan: CU | 22 | SMT vs CPAP | Meeting criteria for ETI during 48 h follow-up; in-hospital mortality | Adequate | Yes | NR | Yes | Adequate | Yes | Adequate |
Kelly et al. 2002 [16] | Scotland, UK: ED and HDU | 58 | SMT vs CPAP | Meeting criteria for treatment failure; in-hospital mortality | Adequate | Yes | NR | Yes | Adequate | Yes | Inadequate |
L'Her et al. 2004 [22] | France: ED | 89 | SMT vs CPAP | Meeting criteria for ETI or death during 48 h follow-up; in-hospital mortality | Adequate | Yes | NR | Yes | Adequate | Yes | Adequate |
Masip et al. 2000 [13] | Spain: ED and ICU | 37 | SMT vs NPPV | Meeting criteria for ETI during 10 h follow-up; in-hospital mortality; AMI incidence | Adequate | Yes | No | Yes | Uncertain | Yes | Adequate |
Levitt et al. 2001 [14] | USA: ED | 38 | SMT vs NPPV | ETI decided by attending physician during 24 h follow-up; in-hospital mortality; AMI incidence. | Adequate | Yes | NR | Uncertain | Uncertain | Yes | Uncertain |
Nava et al. 2003 [19] | Italy: ED | 130 | SMT vs NPPV | Meeting criteria for ETI during 24 h follow-up; in-hospital mortality; AMI incidence | Adequate | Yes | NR | Yes | Adequate | Yes | Adequate |
Mehta et al. 1997 [25] | USA: ED | 27 | CPAP vs NPPV | ETI decided by attending physician during 24 h follow-up; in-hospital mortality; AMI incidence | Adequate | Yes | Yesh | Yes | Adequate | Yes | Uncertain |
Martin-Bermudez et al. 2002 [17] | Spain: ED | 80 | CPAP vs NPPV | Meeting criteria for ETI during 24 h follow-up; in-hospital mortality; AMI incidence | Uncertain | Yes | NR | Uncertain | Adequate | Yes | Uncertain |
Bellone et al. 2004 [20] | Italy: ED | 46 | CPAP vs NPPV | Meeting criteria for ETI during 36 h follow-up; in-hospital mortality; AMI incidence | Adequate | Yes | No | Yes | Adequate | Yes | Adequate |
Bellone et al. 2005 [24] | Italy: ED | 36 | CPAP vs NPPV | Meeting criteria for ETI during 36 h follow-up; in-hospital mortality | Adequate | Yes | No | Yes | Adequate | Yes | Adequate |
Park et al. 2001 [15] | Brazil: ED | 26 | SMT vs CPAP vs NPPV | ETI decided by attending physician during 1 h follow-up; in-hospital mortality; AMI incidence | Uncertain | Yes | NR | Yes | Uncertain | Yes | Inadequate |
Park et al. 2004 [23] | Brazil: ED | 80 | SMT vs CPAP vs NPPV | ETI decided by attending physician during 24 h follow-up; in-hospital mortality; AMI incidence | Adequate | Yes | NR | Yes | Adequate | Yes | Uncertain |
Crane et al. 2004 [21] | UK: ED | 60 | SMT vs CPAP vs NPPV | Meeting criteria for ETI during 2 h follow-up; in-hospital mortality; AMI incidence | Adequate | Yes | No | Yes | Adequate | Yes | Adequate |
Methodological quality of included studies
Reference | Inclusion criteriaa | Exclusion criteria | Baseline co-morbidity: AMI, COPDb | Intervention in experimental group CPAP | Intervention in experimental group NPPV | Intervention in control group SMTc | Objective criteria for endotracheal intubationd |
---|---|---|---|---|---|---|---|
Rasanen et al. 1985 [62] | Clinical criteria of APE; RR >25/min; PaO2/FiO2 <200 | COPD; unresponsive; unable to maintain patent airway; lung infection; pulmonary embolism | AMI: control 10/20; CPAP 9/20 COPD: none | CPAP 10 cmH2O face mask plus medical therapy | - | SMT | Adequate Criteria for ETI: PaO2<50 mmHg; PaCO2 > 55 mmHg; RR >35/min; unresponsiveness; airway obstruction |
Bersten et al. 1991 [63] | Clinical criteria of APE; PaO2 < 70 mmHg; PaCO2 > 45 mmHg when O2 8 l/min | AMI and shock; SBP <90 mmHg; stenotic VHD; COPD and CO2 retention | AMI: control 4/20; CPAP 3/19 COPD: none | CPAP 10 cmH2O face mask plus medical therapy | - | SMT | Adequate Criteria for ETI: clinical deterioration; PaO2 < 70 mmHg with O2 100%; PaCO2 > 55 mmHg |
Lin et al. 1995 [57] | Clinical criteria of APE; PaO2/FIO2 = 200–400; P [A-a] O2 > 250 mmHg | Unresponsive; unable to maintain patent airway; shock; septal rupture; stenotic VHD; COPD and CO2 retention | AMI: control 11/50; CPAP 10/50 COPD: none | CPAP face mask titrated up – 2.5, 5, 7.5, 10 and 12.5 cmH2O plus medical therapy | - | SMT (plus dopamine) | Adequate Criteria for ETI: cardiac resuscitation or clinical deterioration and two of the following – PaCO2 > 55 mmHg, PaO2/FiO2 < 200 mmHg, RR >35 |
Takeda et al. 1997 [11] | Clinical criteria of APE; respiratory distress; PaO2 < 80 mmHg while receiving ≥50% O2 | Not reported | AMI: CPAP 5/15; Control 6/15 COPD: none | CPAP 4–10 cmH2O nasal mask plus medical therapy | - | SMT (plus dopamine, dobutamine, norepinephrine and digitalis) | Adequate Criteria for ETI: clinical deterioration and PaO2/FiO2 <100 mmHg (with FiO2 ≥70%), PaCO2 >55 mmHg |
Takeda et al. 1998 [12] | Clinical criteria of APE; PaO2 < 80 mmHg | Shock; septal or ventricular rupture | All 22 patients with AMI admitted to the coronary unit | CPAP 4–10 cmH2O nasal mask plus medical therapy | - | SMT (plus dopamine, dobutamine, norepinephrine) | Adequate Criteria for ETI: clinical deterioration and PaO2/FiO2 <100 mmHg (with FiO2 ≥70%) PaCO2 >55 mmHg |
Kelly et al. 2002 [16] | Clinical criteria of APE; RR > 20/min | Pneumonia; pneumothorax; pre-hospital treatment with interventions other than oxygen, diuretics or opiates | AMI: not reported COPD: not reported | CPAP 7.5 cmH2O face mask plus medical therapy | - | SMT | Inadequate Criteria for treatment failure: need for intubation (no defined criteria), hypoxemia or hypercapnia and respiratory distress |
L'Her, et al. 2004 [22] | Clinical criteria of APE Age >75 years; PaO2/FiO2 <300 mmHg, RR >25/min | GCS <7; Sat O2 <85%; SBP <90 mmHg); chronic respiratory insufficiency | AMI: not reported (acute ischemic heart disease: control 6/46; CPAP 7/43) COPD: none | Face mask CPAP 7.5 cmH2O plus medical therapy | - | SMT | Adequate Serious complications considered as death or need for ETI within 48 h. Criteria for ETI: cardiac or respiratory arrest; SBP <80 mmHg; progressive hypoxemia (Sat O2 <92%); coma or seizures; agitation |
Masip et al. 2000 [13] | Clinical criteria of APE | AMI; pneumonia; SBP <90 mmHg; CRF; immediate intubation; neurological deterioration | AMI: control 6/18; NPPV 5/19 COPD: control 7/18; NPPV 3/19 | - | NPPV face mask, PEEP 5 cmH2O, plus medical therapy PSV 15.2 ± 2.4 cmH2O | SMT | Adequate Criteria for ETI: cardiac or respiratory arrest, hypoxemia (Sat O2 <80%) and muscles fatigue |
Levitt et al. 2001 [14] | Clinical criteria of APE; RR >30/min | Immediate need for intubation; radiograph not compatible with APE | AMI: none COPD: not reported | - | NPPV S/T mode, face or nasal mask, initial IPAP of 8 and EPAP of 3 cmH2O, pressure support of 5 cmH2O plus medical therapy PSV 5.0 cmH2O | SMT | Uncertain Decision by attending physician based on the following criteria: respiratory distress, deterioration in mental status or vital signs, PaO2 <60 mmHg, PaCO2 >50 mmHg |
Nava et al. 2003 [19] | Clinical criteria of APE; PaO2/FiO2 < 250; RR >30/min | AMI needing thrombolysis; immediate need for intubation; Kelly score >3; shock; arrhythmias; SpO2<80%; severe CRF; pneumothorax | AMI: control 11/65; NPPV 11/65 COPD: control 26/65; NPPV 27/65 | - | NPPV S mode face mask IPAP 14.5 ± 21.1 cmH2O, EPAP: 6.1 ± 3.2 cmH2O plus medical therapy PSV 8.4 cmH2O | SMT | Adequate Sat O2 <85% with FiO2 100%, cardiac or respiratory arrest, inability to tolerate mask, PaCO2 >50 mmHg, signs of pump exhaustion, SBP <90 mmHg, AMI, massive GI bleeding |
Mehta et al. 1997 [25] | Clinical criteria of APE; RR >30/min; tachycardia >100 bpm; without pulmonary aspiration or infection | Immediate need for intubation; respiratory or cardiac arrest; arrhythmias; SBP <90 mmHg; unresponsive; agitated; condition precluding use of face mask | AMI: CPAP 1/13; NPPV 1/14 Chest pain: CPAP 4/13; NPPV 10/14; COPD: not reported | CPAP 10 cmH2O nose/face mask plus medical therapy | NPPV S/T mode, nasal/face mask, IPAP 15 cmH2O, EPAP 5 cmH2O, plus medical therapy PSV 10.0 cmH2O | - | Uncertain Decision by attending physician based on the following criteria: severe respiratory distress, inability to tolerate mask, unstable vital signs, PaO2 <60 mmHg or increase PaCO2 >5 mmHg |
Martin-Bermudez, et al. 2002 [17] | Clinical criteria of APE; RR >25/min; Sat O2 <90% | Not reported | AMI: not reported COPD: not reported | Face mask CPAP plus medical therapy | Face mask NPPV plus medical therapy PSV uncertain | - | Uncertain |
Bellone et al. 2004 [20] | Clinical criteria of APE; Sat O2 <90%; RR >30/min | Acute coronary syndrome; immediate need for intubation; respiratory or cardiac arrest; SBP <90 mmHg; unresponsive, agitated or unable to cooperate; condition precluding use of face mask | AMI: none COPD: CPAP 8/22; NPPV 6/24 | Face mask CPAP 10 cmH2O plus medical therapy | Face mask NPPV initially IPAP 15 cmH2O and EPAP 5 cmH2O, with adjustments as needed to obtain tidal volume >400 ml plus medical therapy PSV 10.0 cmH2O | - | Adequate Respiratory arrest; loss of consciousness; agitation; heart rate <50/min, SBP <70 mmHg |
Bellone et al. 2005 [24] | Clinical criteria of APE; PaCO2 > 45 mmHg; Sat O2 <90%; RR >30/min | COPD; PaCO2 <45 mmHg; immediate need for intubation; respiratory or cardiac arrest; SBP <90 mmHg; CRF; agitated; condition precluding use of face mask; enrolled in other study | AMI: CPAP 0/18; NPPV 2/18 COPD: none | Face mask CPAP 10 cmH2O plus medical therapy | Face mask NPPV initially IPAP 15 cmH2O, EPAP 5 cmH2O, adjustments to obtain tidal volume >400 ml plus medical therapy PSV 10.0 cmH2O | - | Adequate Respiratory arrest; loss of consciousness; agitation; heart rate <50/min, SBP <70 mmHg |
Park et al. 2001 [15] | Clinical criteria of APE; RR >25/min | COPD; SBP <90 mmHg; arrhythmias; bradypnea; unresponsive, agitated or unable to cooperate; vomiting; digestive hemorrhage; facial deformities | AMI: control 2/10; CPAP 1/9; NPPV 1/7 COPD: none | Face mask CPAP mean 7.5 cmH2O, initially 5, increased by 2.5, maximum 12.5 cmH2O, plus medical therapy | NPPV S/T mode nasal mask, IPAP 12 cmH2O, EPAP 4 cmH2O, plus medical therapy PSV 8.0 cmH2O | SMT | Inadequate Decision made by the attending physician based on clinical and laboratory findings |
Park et al. 2004 [23] | Clinical criteria of APE; RR >25/min | AMI; COPD; pulmonary embolism; pneumonia; pneumothorax; SBP <90 mmHg; vomiting | AMI: control 3/26; CPAP 1/27; NPPV 1/27 COPD: none | Face mask CPAP initially 11 ± 2 cmH2O plus medical therapy | Face mask NPPV, IPAP 17 ± 2 cmH2O, EPAP 11 ± 2 cmH2O, plus medical therapy PSV 6.0 cmH2O | SMT | Uncertain Decision made by the attending physician based on the following criteria: GCS <13, respiratory distress, PaO2 <60 mmHg, Sat O2 <90%, increase PaCO2 >5 mmHg |
Crane et al. 2004 [21] | Clinical criteria of APE; RR >23/min; pH <7.35 | SBP <90 mmHg; temperature >38°C; AMI with thrombolysis; dialysis for CRF; impaired consciousness; dementia | AMI: none COPD: control 6/20; CPAP 3/20; NPPV 7/20 | Face mask CPAP 10 cmH O plus medical therapy | Face mask NPPV IPAP 15 cmH2O, EPAP 5 cmH2O plus medical therapy PSV 10.0 cmH2O | SMT | Adequate RR >40 or <10 and reduced consciousness; falling pH (<7.2) |
Continuous positive airway pressure ventilation versus standard medical therapy
Non-invasive positive pressure ventilation versus standard medical therapy
Continuous positive airway pressure ventilation versus non-invasive positive pressure ventilation
Publication bias
Discussion
Conclusion
Key messages
-
CPAP and NPPV have gained decisive roles in the management of various forms of respiratory failure, namely ACPE.
-
In this meta-analysis we show that, in ACPE patients, CPAP and NPPV both significantly decrease the need for ETI, and CPAP significantly reduces mortality when compared to SMT. The evidence is now robust, and the use of these techniques as a first line intervention in ACPE patients is becoming mandatory.
-
Although both techniques, CPAP and NPPV, showed similar efficacy in decreasing need for ETI and mortality, CPAP has been shown to be cheaper and easier to use and implement in clinical practice, so it could be considered the preferred intervention in ACPE patients.
-
Analysis of the safety of these methods showed that, although some caution is still advised, there is no evidence of increased risk of AMI with either of these techniques and other adverse events described are very rare.
-
No evidence supporting the suggested superiority of NPPV in hypercapnic ACPE patients was found and the advantage of higher levels of pressure support ventilation when using NPPV was not confirmed.