Peter John Victor, Moran John L, Phillips-Hughes Jennie, Graham Petra, Bersten Andrew D
Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Woodville South, SA 5011, Australia.
Lancet. 2006 Apr 8;367(9517):1155-63. doi: 10.1016/S0140-6736(06)68506-1.
Non-invasive positive pressure ventilation (NIPPV), using continuous positive airway pressure (CPAP) or bilevel ventilation, has been shown to reduce the need for invasive mechanical ventilation in patients with acute cardiogenic pulmonary oedema. We assessed additional benefits of NIPPV in a meta-analysis.
Meta-analysis comparison in acute cardiogenic pulmonary oedema was undertaken to compare (1) CPAP with standard therapy (oxygen by face-mask, diuretics, nitrates, and other supportive care), (2) bilevel ventilation with standard therapy, and (3) bilevel ventilation with CPAP, incorporating randomised controlled trials identified by electronic and hand search (1966-May, 2005). In 23 trials that fulfilled inclusion criteria, we assessed the effect of NIPPV on hospital mortality and mechanical ventilation, estimated as relative risks.
CPAP was associated with a significantly lower mortality rate than standard therapy (relative risk 0.59, 95% CI 0.38-0.90, p=0.015). A non-significant trend towards reduced mortality was seen in the comparison between bilevel ventilation and standard therapy (0.63, 0.37-1.10, p=0.11). We recorded no substantial difference in mortality risk between bilevel ventilation and CPAP (p=0.38). The need for mechanical ventilation was reduced with CPAP (0.44, 0.29-0.66, p=0.0003) and with bilevel ventilation (0.50, 0.27-0.90, p=0.02), compared with standard therapy; but no significant difference was seen between CPAP and bilevel ventilation (p=0.86). Weak evidence of an increase in the incidence of new myocardial infarction with bilevel ventilation versus CPAP was recorded (1.49, 0.92-2.42, p=0.11). Heterogeneity of treatment effects was not evident for mortality or mechanical ventilation across patients' groups.
In patients with acute cardiogenic pulmonary oedema, CPAP and bilevel ventilation reduces the need for subsequent mechanical ventilation. Compared with standard therapy, CPAP reduces mortality; our results also suggest a trend towards reduced mortality after bilevel NIPPV.
无创正压通气（NIPPV），采用持续气道正压通气（CPAP）或双水平通气，已被证明可减少急性心源性肺水肿患者对有创机械通气的需求。我们通过荟萃分析评估了NIPPV的额外益处。
对急性心源性肺水肿进行荟萃分析比较，以比较（1）CPAP与标准治疗（面罩吸氧、利尿剂、硝酸盐及其他支持治疗），（2）双水平通气与标准治疗，以及（3）双水平通气与CPAP，纳入通过电子检索和手工检索（1966年 - 2005年5月）确定的随机对照试验。在23项符合纳入标准的试验中，我们评估了NIPPV对医院死亡率和机械通气的影响，以相对风险进行估计。
CPAP与标准治疗相比，死亡率显著降低（相对风险0.59，95%可信区间0.38 - 0.90，p = 0.015）。双水平通气与标准治疗比较时，死亡率有降低趋势但不显著（0.63，0.37 - 1.10，p = 0.11）。我们记录到双水平通气与CPAP之间的死亡风险无显著差异（p = 0.38）。与标准治疗相比，CPAP（0.44，0.29 - 0.66，p = 0.0003）和双水平通气（0.50，0.27 - 0.90，p = 0.02）可减少机械通气需求；但CPAP与双水平通气之间无显著差异（p = 0.86）。记录到双水平通气与CPAP相比，新发心肌梗死发生率增加的证据较弱（1.49，0.92 - 2.42，p = 0.11）。不同患者组间在死亡率或机械通气方面，治疗效果的异质性不明显。
在急性心源性肺水肿患者中，CPAP和双水平通气可减少后续机械通气的需求。与标准治疗相比，CPAP可降低死亡率；我们的结果还表明双水平NIPPV后死亡率有降低趋势。
