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NIPPV for acute cardiogenic pulmonary oedema
  1. Rupert Jackson, Specialist Registrar in Emergency Medicine,
  2. Steve Jones, Specialist Registrar in Emergency Medicine
  1. Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
  1. Correspondence to: Kevin Mackway-Jones, Consultant (kevin.mackway-jones{at}

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Report by Rupert Jackson,Specialist Registrar in Emergency MedicineChecked by Steve Jones,Specialist Registrar in Emergency Medicine

Clinical scenario

A 76 year old man is brought in to the emergency department 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 diminshed 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 positive pressure ventilation (NIPPV).

Three part question

In [patients with acute LVF] is [NIPPV better than alternative treatment strategies] at [avoiding intubation and improving mortality]?

Search strategy

Medline 1966–08/01 using the OVID interface. [exp pulmonary edema/ or “pulmonary edema”.mp or exp ventricular dysfunction, left/ or exp heart failure, congestive/ or exp myocardial infarction/ or “Left ventricular failure”.mp or “lvf”.mp] AND [exp positive-pressure respiration/ or exp intermittent positive-pressure ventilation/ or exp respiration, artificial/ or “non-invasive ventilation”.mp or “bilevel”.mp or “BiPAP”.mp or “pressure support”.mp] LIMIT to (human and english language) AND maximally sensitive RCT filter.

Search outcome

Altogether 208 papers were found, of which four randomised controlled trials directly addressed the three part question (table 4).

Table 4


This group of trials compared NIPPV with different alternative treatments; oxygen, continuous positive airways pressure (CPAP) or high dose medical therapy. One study showed a benefit in the reduction of intubation rates when NIPPV is compared to oxygen alone, but others have reported evidence of harm with an increased incidence of myocardial infarction in the NIPPV groups. CPAP has already been shown to be of benefit in this patient group.5

Clinical bottom line

The evidence for the use of NIPPV in acute pulmonary oedema is moot. At present CPAP is the safer proven option.

Report by Rupert Jackson,Specialist Registrar in Emergency MedicineChecked by Steve Jones,Specialist Registrar in Emergency Medicine


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