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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Is noninvasive pressure support ventilation as effective and safe as continuous positive airway pressure in cardiogenic pulmonary oedema?

R Agarwal, AN Aggarwal, and D Gupta.

Review published: 2009.

Link to full article: [Journal publisher]

CRD summary

This review concluded that noninvasive pressure support ventilation appeared to be as safe and efficacious as continuous positive airway pressure in treatment of acute cardiogenic pulmonary oedema if titrated rather than fixed pressures were employed. The authors' conclusions reflected the evidence presented and are likely to be reliable.

Authors' objectives

To compare the efficacy and safety of noninvasive pressure support ventilation with continuous positive airway pressure in the treatment of acute cardiogenic pulmonary oedema.

Searching

MEDLINE and EMBASE were searched without language restrictions for published studies from 1980 to 2008. Search terms were reported. Reference lists of retrieved publications were screened. The authors' personal files were handsearched.

Study selection

Randomised controlled trials (RCTs) that compared noninvasive pressure support ventilation with continuous positive airway pressure in patients at least 19 years old with acute cardiogenic pulmonary oedema were eligible for inclusion. The review outcomes were endotracheal intubation, myocardial infarction and hospital mortality.

The included studies were published between 1997 and 2008. Most studies used variable levels of noninvasive pressure support ventilation and continuous positive airway pressure. Some studies used fixed airway pressure. In most studies, patients' mean partial pressure of carbon dioxide in arterial blood at entry was more than 45mmHg. Mean age of included patients ranged from 44 to 89 years. Patients' Acute Physiology and Chronic Health Evaluation (APACHE) II scores varied from 14 to 25.

The authors did not state how many reviewers performed the study selection.

Assessment of study quality

Study quality was assessed using the Jadad scale, a five-point evaluation scale for randomisation, blinding and withdrawals. Studies that scored 3 were classed as high quality.

The authors did not state how many reviewers performed the validity assessment.

Data extraction

Data were extracted on the number of patients who experienced an event to enable calculation of odds ratios (ORs) and 95% confidence intervals (CIs).

Two reviewers independently performed data extraction. Any disagreements were resolved by consensus or in consultation with a third reviewer.

Methods of synthesis

Studies were combined in meta-analyses. Pooled ORs with 95% CIs were calculated using the fixed-effect model of Mantel-Haenszel, random-effects model of DerSimonian and Laird and the exact method of Martin and Austin, as appropriate; only the figures of random-effects models were presented in the report. Statistical heterogeneity was assessed using the Cochran Q and I2 statistics. Publication bias was investigated using funnel plots, Egger test, Begg and Mazumdar’s test and Harbord’s test. Subgroup analyses were conducted on different types of pressure therapy (fixed pressure versus variable pressure).

Results of the review

Ten RCTs were included in meta-analyses (n=1,153). Sample sizes varied from 16 to 702. The median Jadad score of included studies was 3. Most studies were judged as good quality.

Compared to continuous positive airway pressure, noninvasive pressure support ventilation had no significant differences in the rate of intubation (OR 0.80, 95% CI 0.43 to 1.49; 10 RCTs), occurrence of myocardial infarction (OR 0.8, 95% CI 0.36 to1.54; eight RCTs) and hospital mortality (OR 1.08, 95% CI 0.76 to1.54; 10 RCTs ).

Subgroup analyses showed that fixed pressure noninvasive pressure support ventilation was associated with a significant increase in myocardial infarction compared with continuous positive airway pressure (OR 5.06, 95% CI 1.66 to 15.44; two RCTs)

No statistically significant heterogeneity was observed. No evidence of publication bias was found according to visual scanning of forest plots and the statistical tests.

Authors' conclusions

Noninvasive pressure support ventilation appeared as safe and efficacious as continuous positive airway pressure in the treatment of acute cardiogenic pulmonary oedema if titrated rather than fixed pressures were employed.

CRD commentary

This review's inclusion criteria were clear. Relevant databases were searched. Efforts were made to find published studies, but not unpublished studies; this introduced potential for publication bias. Publication bias was assessed and little evidence of it was found. No language restrictions were applied, which limited the possibility of language bias. Steps were taken to minimise bias by having more than one reviewer independently undertake data extraction; it was unclear whether the processes of study selection and validity assessment were performed in duplicate. Relevant criteria were used to examine study quality. Statistical heterogeneity was assessed and appropriate methods were used to pool results. The authors' conclusions reflected the evidence presented and are likely to be reliable.

Implications of the review for practice and research

Practice: The authors stated that noninvasive ventilation should be used in a protocol where positive pressure therapy is titrated to specific clinical blood gases and spirometric end-points rather than using fixed pressures.

Research: The authors did not state any implications for research.

Funding

Not stated.

Bibliographic details

Agarwal R, Aggarwal AN, Gupta D. Is noninvasive pressure support ventilation as effective and safe as continuous positive airway pressure in cardiogenic pulmonary oedema? Singapore Medical Journal 2009; 50(6): 595-603. [PubMed: 19551313]

Indexing Status

Subject indexing assigned by NLM

MeSH

Aged; Continuous Positive Airway Pressure /methods; Humans; Middle Aged; Odds Ratio; Oxygen Inhalation Therapy /methods; Pulmonary Edema /therapy; Randomized Controlled Trials as Topic; Respiration, Artificial; Safety; Treatment Outcome

AccessionNumber

12009107908

Database entry date

24/03/2010

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 19551313

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