The use of noninvasive ventilation in emergency department patients with acute cardiogenic pulmonary edema: a systematic review.

STUDY OBJECTIVE Acute cardiogenic pulmonary edema is a common cause of respiratory distress in emergency department (ED) patients. Noninvasive ventilation by noninvasive positive pressure ventilation or continuous positive airway pressure has been studied as a treatment strategy. We critically evaluate the evidence for the use of noninvasive ventilation on rates of hospital mortality and endotracheal intubation. METHODS We searched the databases of MEDLINE, EMBASE, and the Cochrane Library from 1980 to 2005. Additional sources included key journals, bibliographies of selected articles, and expert contact. We included studies that incorporated a randomized design; patients older than 18 years and with acute cardiogenic pulmonary edema; diagnosis and treatment initiated in the ED; noninvasive ventilation in addition to standard medical therapy compared to standard medical therapy alone, or noninvasive positive pressure ventilation compared to continuous positive airway pressure (both in addition to standard medical therapy); and data on hospital mortality or intubation. A random-effects model was used to obtain the summary risk ratios (RRs) and 95% confidence intervals (CIs) for hospital mortality and intubation. RESULTS A pooled analysis of 494 patients suggested that noninvasive ventilation in addition to standard medical therapy significantly reduced hospital mortality compared to standard medical therapy alone (RR 0.61; [95% CI 0.41, 0.91]). Similarly, a meta-analysis of 436 patients suggested that noninvasive ventilation was associated with a significant decrease in intubation rates (RR 0.43; [95% CI 0.21, 0.87]). CONCLUSION Our results suggest that noninvasive ventilation with standard medical therapy is advantageous over standard medical therapy alone in ED patients with acute cardiogenic pulmonary edema. Future studies, powered appropriately for mortality and intubation rates, are necessary to confirm these findings.