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At the recent third conference on retroviruses and opportunistic infections, preliminary data were presented on the triple combination of epivir + retrovir + indinavir protease inhibitor and esidrix.
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Analyes published in major journals by two different sets of authors on the same topic. Although these probably don't review any major new studies compared to the JAMA study, they confirm the results of the JAMA study: NIPPV is outstanding for patients with dCHF and cardiogenic pulmonary edema CPE ; . The authors of the first article reviewed 23 trials and found that when either CPAP or BiPAP were used, there was evidence of decreased mortality relative risk 0.59 for CPAP, 0.63 for BiPAP ; and need for mechanical ventilation RR 0.44 for CPAP, 0.50 for BiPAP ; . There was no significant difference between CPAP and BiPAP. There also was no evidence of differences in other treatments between the groups, so the difference in outcomes seemed to be directly related to use of the NIPPV. The authors of the second article evaluated MEDLINE, EMBASE, and the Cochrane Library from 1980-2005. I won't go into details of how they chose articles for evaluation, but they ended up doing a pooled analysis of 494 patients that were treated with "standard" medical therapy, and they found that the addition of NIV significantly reduced hospital mortality RR 0.61 ; . Another analysis of 436 patients found that NIV was associated with a significant decrease in intubation rates RR 0.43 ; . Individual studies have also demonstrated that this results in decreased ICU bed utilization, hospital length of stay, and hospital costs. To put this in proper perspective, there are no other individual acute therapies that have been shown to decrease hospital mortality in patients with CPE.not NTG, not nesiritide, not diuretics, not even ACEIs though perhaps due to lack of large studies? ; . Early use of NIV may very well be the most important thing you can do for your patients with CPE. A key word to remember here, though, is "early." NIPPV works best when used early. If you wait until the patient is starting to look worse, it's too late. You should use the NIPPV as soon as the patient with presumed dCHF arrives. Also remember that, unlike many other therapies, NIPPV works nicely in many other conditions that cause dyspnea as well, so it tends to be useful even if the patient ends up having an alternative diagnosis. This is especially important in the prehospital setting where misdiagnosis of dyspneic patients is common and oretic.
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