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Noninvasive Positive-Pressure Ventilation for Acute Respiratory Failure: Comparative Effectiveness

Slide: 18 of 25

Noninvasive Positive-Pressure Ventilation With BPAP Versus CPAP in Patients With ACPE

There was moderate-strength evidence that mortality did not differ significantly when providing noninvasive positive-pressure ventilation (NPPV) with continuous positive airway pressure (CPAP) versus bilevel positive airway pressure (BPAP). Ten studies assessed the effects of BPAP versus CPAP on mortality. Seven of the studies evaluated CPAP versus BPAP, while three studies had a third comparison arm where patients received supplemental oxygen alone. In-hospital mortality ranged from 0–25 percent for BPAP, 0–21 percent for CPAP, and 0–30 percent for oxygen alone. Overall, there was no difference in in-hospital mortality between the BPAP and CPAP groups in a random-effects model meta-analysis (odds ratio [OR] = 0.89; 95-percent confidence interval [95% CI], 0.58 to 1.35) drawn from a total of 10 studies. Mortality was generally assessed across the duration of hospitalization (nine studies), although one study reported 7-day mortality. It should be noted that fewer than 2 percent of patients enrolled in these studies carried a primary diagnosis other than acute cardiogenic pulmonary edema (ACPE). Based on direct comparisons, no conclusions can be made about the effect of BPAP versus CPAP for patients with respiratory failure of other etiologies.

Endotracheal intubation rates did not differ significantly when providing NPPV with BPAP versus CPAP. The strength of evidence for this finding was rated as moderate. Twelve studies assessed the effects of BPAP versus CPAP on endotracheal intubation rates. Eight of the studies evaluated CPAP versus BPAP, while four studies had a third comparison arm where patients received supplemental oxygen alone. Endotracheal intubation rates ranged from 0–29 percent for BPAP, 0–33 percent for CPAP, and 2.8–42 percent for oxygen alone. Based on an analysis of 12 studies, there was no difference in the incidence of endotracheal intubation between the BPAP and CPAP groups in a random-effects model meta-analysis (OR = 0.84; 95% CI, 0.51 to 1.38). No significant variability in treatment effects across studies was detected. Similar to the studies reporting on mortality, fewer than 2 percent of patients enrolled in these studies carried a primary diagnosis other than ACPE.

There was low-strength evidence that myocardial infarction rates did not differ significantly when providing NPPV with BPAP versus CPAP. Seven studies assessed the effects of BPAP versus CPAP on myocardial infarction rates. Five of the studies evaluated CPAP versus BPAP, while two studies had a third comparison arm where patients received supplemental oxygen alone. All studies were conducted in patients with ACPE. Myocardial infarction rates ranged from 0–71 percent for BPAP, 7–31 percent for CPAP, and 0–30 percent for oxygen alone. Overall, there was no significant difference in myocardial infarction rates when NPPV was applied with BPAP versus CPAP (OR = 0.69; 95% CI, 0.34–1.40). There was moderate heterogeneity in treatment effects across studies.