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CPAP in acute left ventricular failure
  1. Rupert Jackson,
  2. Simon Carley
  1. Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M139WL, UK

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    Report by Rupert Jackson, Specialist Registrar Search checked by Simon Carley, Specialist Registrar

    Clinical scenario

    A 76 year old man is brought into accident and emergency in a collapsed state. He has a history of ischaemic heart disease. He is agitated, tachypnoeic and sweating profusely. His neck veins are distended and there are widespread coarse crepitations in his chest. He has a diminished oxygen saturation. You make a clinical diagnosis of acute cardiogenic pulmonary oedema. In addition to vasodilator treatment and opioids, you wonder whether you should administer non-invasive continuous positive airways pressure (CPAP).

    Three part question

    [In patients with acute LVF] is [CPAP better than O2 via normal mask] at [avoiding intubation and improving mortality]?

    Search strategy

    Medline 1966–09/00 using the OVID interface. ([exp pulmonary edema OR pulmonary OR exp ventricular dysfunction, left OR exp heart failure, congestive OR exp myocardial infarction OR left ventricular OR AND (exp positive-pressure respiration OR OR continuous positive airway pressure$.mp OR OR positive end expiratory pressure$.mp] AND maximally sensitive randomised controlled trial filter) LIMIT to human AND english language

    Search outcome

    Altogether 114 papers were found of which 109 were either irrelevant or of insufficient quality for inclusion. The remaining five papers are shown in table 6.

    Table 6


    All of these trials have shown significant reductions in the need to intubate patients in acute pulmonary oedema. In these small trials a reduction in mortality could not be seen. The numbers in the trials are not large and there is not yet absolute evidence of benefit from CPAP. A large, well designed PRCT may provide this. In the meantime it would seem that patients with severe LVF will benefit from CPAP.

    Clinical bottom line

    Patients presenting with severe acute pulmonary oedema should be treated with CPAP.

    Report by Rupert Jackson, Specialist Registrar Search checked by Simon Carley, Specialist Registrar