BEST EVIDENCE TOPIC REPORT by QmTWycm

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									BEST EVIDENCE TOPIC REPORT


 USE OF CONTINUOUS POSITIVE
  AIRWAY PRESSURE IN ACUTE
   CARDIOGENIC PULMONARY
           OEDEMA

     Andy Ratchford SpR A&E
         November 2000
    CLINICAL SCENARIO

A 72 year old woman attends A&E
with shortness of breath. You make a
diagnosis of acute cardiogenic
pulmonary oedema. You wonder
whether treatment with CPAP is better
than O2 alone at avoiding endotracheal
intubation.
  THREE PART QUESTION
In [adults with acute cardiogenic
pulmonary oedema] is [continuous
positive airway pressure applied by
face mask better than oxygen alone] in
[avoiding the need for endotracheal
intubation and mechanical
ventilation]?
      SEARCH STRATEGY
Medline via OVID interface 1966 to
10/2000 as follows:
(exp Pulmonary edema/th or exp Heart
failure,congestive/th or exp Ventricular
dysfunction,left/th) and (exp positive-
pressure respiration or “continuous
positive airway pressure”.mp) limit to
(human and english language)
       SEARCH OUTCOME
• 191 papers identified, only 4 relevant
  prospective randomised controlled
  trials.
• BiPAP, nasal CPAP and use of CPAP
  in children were excluded.
• These papers are shown in the
  following table.
            Patient     Outcomes           Results              Comments
            groups

R senen       40 pts   Need to intubate   7/20 v 13/20 (NS)    Medical treatment
1985           O2 vs                                            not resticted
Finland      10cmH2O    Hospital mortality NS                   Small
              CPAP

Lin            80 pts   Need to intubate   7/25 v 17/30 (P<0.05) No randomisation
1991           O2 vs                                             details
Taiwan      incremental 24 hr mortality    NS                    Medical treatment
               CPAP                                              not restricted
                                                                 “sloppy”
Bersten        40 pts   Need to intubate   0/19 v 7/20 (P<0.005) Randomisation bias
1991           O2 vs
Australia    10cmH2O    Hospital mortality NS                   Small
              CPAP
Lin           100 pts   Need to intubate   8/50 v 18/50 (P<0.01) Recruitment bias
1995           O2 vs                                             No randomisation
Taiwan      incremental Hospital mortality NS                    details
               CPAP
            CONCLUSIONS
• 3 of the 4 trials show a significant benefit of
  reducing the need for intubation with
  CPAP. The other trial showed a non
  significant benefit.
• There was no overall improvement in
  mortality in this patient group with the use
  of CPAP.
    CLINICAL BOTTOM LINE
• In adults with acute cardiogenic pulmonary
  oedema CPAP therapy is more effective
  than O2 alone in avoiding the need for
  endotracheal intubation and mechanical
  ventilation.
• Use of CPAP should be considered a
  routine treatment in these patients.
                  REFERRENCES

• 1. Rsnen J, et al. Continuous positive airway pressure by face
  mask in acute cardiogenic pulmonary oedema. Am J Cardiol
  1985;55:296-300
• 2.Lin M, et al. The efficacy of early continuous positive airway
  pressure therapy in patients with acute cardiogenic pulmonary oedema.
  J Formosan Med Assoc 1991;90(8):736-743
• 3.Bersten AD, et al. Treatment of severe cardiogenic pulmonary
  oedema with continuous positive airway pressure delivered by face
  mask. N Engl J Med 1991;325(26):1825-1830
• 4.Lin M, et al. Reappraisal of continuous positive airway pressure
  therapy in acute cardiogenic pulmonary oedema: short-term results and
  long-term follow-up. Chest 1995;107(5):1379-1386

								
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