Wednesday, May 03, 2006

CPAP and BiPAP in acute pulmonary edema---evidence based and ready for prime time

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.”

2 comments:

CPAP said...

Great, hopeful results.

Anonymous said...

1/27/07-My husband has what iI believe is a severe respiratory broncho-pneumonia, worsening over the past 3days. He has had a 4-way heart bypass(CABG)15 years ago and has been "well" but does require furosemide 1-2 x week for pedal edems. this evening he suddenly got much better with constant cough, voluminous mucopurulent sputum and some SOB, respiratory rate 28/minute. some of the sputum was frothy and blood tinged. I thought he was getting into pulmonary edema and started doing what I could to avoid a flying trip to the ER which is 100 miles away. I hooked him up to my CPAP set at 10 centimeters and he ws immediately "felt better". After a web search I added 40 mgs furosemide and fruit juice to avoid hypoglycemia (he has type 2 DM and has taken all of his medicines). He is resting now and says why go to the ER? He feels much better. O2 sats are 94-96,Pulse has dropped to the 70's, rr is 20-24 and easy. I believe the CPAP was the thing that did him the most good. If he does deteriorate we can use the CPAP in our vdhicle and take him to the ER later tonight. Your information was helpful and re-assuring. Thanks a retired physician.