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evident
Original paper
2008NEJMEmergency Medicine

3CPO

Noninvasive ventilation in acute cardiogenic pulmonary edema

RCTCardiogenic pulmonary edema

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Overview

In acute cardiogenic pulmonary edema, noninvasive ventilation eased distress and gas exchange faster than oxygen but did not cut 7-day mortality.

Clinical takeaway

3CPO supports NIV for faster relief of pulmonary edema symptoms, not as a proven mortality-reducing therapy compared with oxygen.

Key result

7-day mortality was 9.5% with noninvasive ventilation vs 9.8% with standard oxygen (not significant).

Practice impact

Use CPAP or NIPPV to improve dyspnea and gases in cardiogenic pulmonary edema; do not expect a 7-day survival difference versus oxygen.

Evidence

Study design

Multicenter, open, prospective, randomized, controlled trial.

Enrollment

1,069

Follow-up

Death within 7 days; death or intubation within 7 days for the CPAP versus NIPPV comparison.

Geography

Not listed

Clinical question

Does noninvasive ventilation reduce 7-day mortality compared with standard oxygen in acute cardiogenic pulmonary edema, and do CPAP and NIPPV differ?

Population

  • Patients with acute cardiogenic pulmonary edema (mean age 77.7 years; 56.9% female).

Intervention

Noninvasive ventilation with CPAP (5 to 15 cm of water) or NIPPV (inspiratory 8 to 20 cm of water; expiratory 4 to 10 cm of water).

Comparator

Standard oxygen therapy.

Primary outcome

Death within 7 days for noninvasive ventilation versus oxygen; death or intubation within 7 days for NIPPV versus CPAP.

Noninvasive ventilation did not reduce 7-day mortality compared with standard oxygen, though it improved dyspnea and metabolic disturbance faster.

p=0.87

Key results

  • 7-day mortality was 9.5% with noninvasive ventilation vs 9.8% with standard oxygen (P=0.87).
  • Death or intubation within 7 days was 11.7% with CPAP vs 11.1% with NIPPV (P=0.81).
  • At 1 hour, noninvasive ventilation improved dyspnea, heart rate, acidosis, and hypercapnia more than standard oxygen.
  • There were no treatment-related adverse events.

Harms

  • There were no treatment-related adverse events.

Clinical Use

Practice impact

  • Use CPAP or NIPPV to improve dyspnea and gases in cardiogenic pulmonary edema; do not expect a 7-day survival difference versus oxygen.

Applicability

  • Most applicable to patients presenting with acute cardiogenic pulmonary edema who can be assigned to oxygen, CPAP, or NIPPV.

Limitations

  • The trial was open-label.
  • The mortality comparison pooled CPAP and NIPPV against oxygen.
  • Absence of reported treatment-related adverse events does not mean NIV is risk-free in every patient.

Common misinterpretations

  • No mortality benefit is not the same as no clinical benefit; dyspnea, heart rate, pH, and carbon dioxide improved faster.
  • CPAP and NIPPV were similar for death or intubation; the trial does not pick a clearly superior NIV mode.

Citation

Gray A, Goodacre S, Newby DE, et al. Noninvasive ventilation in acute cardiogenic pulmonary edema. N Engl J Med. 2008;359(2):142-151. doi:10.1056/NEJMoa0707992

In patients with acute cardiogenic pulmonary edema, noninvasive ventilation induces a more rapid improvement in respiratory distress and metabolic disturbance than does standard oxygen therapy but has no effect on short-term mortality.