ER and critical care docs I’ve worked around seem to have figured this out some time ago, and now we have high level evidence to support the use of these modalities in acute cardiogenic pulmonary edema (ACPE). The meta-analysis just published in Critical Care provided robust evidence that non invasive (usually via face mask) continuous positive airway pressure (CPAP) and non invasive continuous positive pressure ventilation (NPPV, more popularly known as BiPAP), when combined with standard medical therapy (SMT) reduce mortality and the need for intubation when compared to SMT alone.
Absolute risk reductions were striking, with numbers needed to treat (NNT) for CPAP of 4.5 in preventing need for intubation and 8 to save one life. For NPPV the NNTs were 5.6 and 14 respectively. All of those results were statistically significant except for the effect of NPPV on mortality, in which the confidence interval overlapped zero. A few studies in the analysis compared the two modalities, showing a non statistically significant trend in favor of NPPV.
The authors conclude that these modalities, which already had a class IIa recommendation in the 2005 guidelines for management of acute heart failure from the European Society of Cardiology, are first line interventions and should be considered “mandatory.”