TY - JOUR

T1 - Noninvasive respiratory support following extubation in critically ill adults

T2 - a systematic review and network meta-analysis

AU - Fernando, Shannon M.

AU - Tran, Alexandre

AU - Sadeghirad, Behnam

AU - Burns, Karen E. A.

AU - Fan, Eddy

AU - Brodie, Daniel

AU - Munshi, Laveena

AU - Goligher, Ewan C.

AU - Cook, Deborah J.

AU - Fowler, Robert A.

AU - Herridge, Margaret S.

AU - Cardinal, Pierre

AU - Jaber, Samir

AU - Moller, Morten Hylander

AU - Thille, Arnaud W.

AU - Ferguson, Niall D.

AU - Slutsky, Arthur S.

AU - Brochard, Laurent J.

AU - Seely, Andrew J. E.

AU - Rochwerg, Bram

PY - 2022

Y1 - 2022

N2 - Purpose Systematic review and network meta-analysis to investigate the efficacy of noninvasive respiratory strategies, including noninvasive positive pressure ventilation (NIPPV) and high-flow nasal cannula (HFNC), in reducing extubation failure among critically ill adults. Methods We searched databases from inception through October 2021 for randomized controlled trials (RCTs) evaluating noninvasive respiratory support therapies (NIPPV, HFNC, conventional oxygen therapy, or a combination of these) following extubation in critically ill adults. Two reviewers performed screening, full text review, and extraction independently. The primary outcome of interest was reintubation. We used GRADE to rate the certainty of our findings. Results We included 36 RCTs (6806 patients). Compared to conventional oxygen therapy, NIPPV (OR 0.65 [95% CI 0.52-0.82]) and HFNC (OR 0.63 [95% CI 0.45-0.87]) reduced reintubation (both moderate certainty). Sensitivity analyses showed that the magnitude of the effect was highest in patients with increased baseline risk of reintubation. As compared to HFNC, no difference in incidence of reintubation was seen with NIPPV (OR 1.04 [95% CI 0.78-1.38], low certainty). Compared to conventional oxygen therapy, neither NIPPV (OR 0.8 [95% CI 0.61-1.04], moderate certainty) or HFNC (OR 0.9 [95% CI 0.66-1.24], low certainty) reduced short-term mortality. Consistent findings were demonstrated across multiple subgroups, including high- and low-risk patients. These results were replicated when evaluating noninvasive strategies for prevention (prophylaxis), but not in rescue (application only after evidence of deterioration) situations. Conclusions Our findings suggest that both NIPPV and HFNC reduced reintubation in critically ill adults, compared to conventional oxygen therapy. NIPPV did not reduce incidence of reintubation when compared to HFNC. These findings support the preventative application of noninvasive respiratory support strategies to mitigate extubation failure in critically ill adults, but not in rescue conditions.

AB - Purpose Systematic review and network meta-analysis to investigate the efficacy of noninvasive respiratory strategies, including noninvasive positive pressure ventilation (NIPPV) and high-flow nasal cannula (HFNC), in reducing extubation failure among critically ill adults. Methods We searched databases from inception through October 2021 for randomized controlled trials (RCTs) evaluating noninvasive respiratory support therapies (NIPPV, HFNC, conventional oxygen therapy, or a combination of these) following extubation in critically ill adults. Two reviewers performed screening, full text review, and extraction independently. The primary outcome of interest was reintubation. We used GRADE to rate the certainty of our findings. Results We included 36 RCTs (6806 patients). Compared to conventional oxygen therapy, NIPPV (OR 0.65 [95% CI 0.52-0.82]) and HFNC (OR 0.63 [95% CI 0.45-0.87]) reduced reintubation (both moderate certainty). Sensitivity analyses showed that the magnitude of the effect was highest in patients with increased baseline risk of reintubation. As compared to HFNC, no difference in incidence of reintubation was seen with NIPPV (OR 1.04 [95% CI 0.78-1.38], low certainty). Compared to conventional oxygen therapy, neither NIPPV (OR 0.8 [95% CI 0.61-1.04], moderate certainty) or HFNC (OR 0.9 [95% CI 0.66-1.24], low certainty) reduced short-term mortality. Consistent findings were demonstrated across multiple subgroups, including high- and low-risk patients. These results were replicated when evaluating noninvasive strategies for prevention (prophylaxis), but not in rescue (application only after evidence of deterioration) situations. Conclusions Our findings suggest that both NIPPV and HFNC reduced reintubation in critically ill adults, compared to conventional oxygen therapy. NIPPV did not reduce incidence of reintubation when compared to HFNC. These findings support the preventative application of noninvasive respiratory support strategies to mitigate extubation failure in critically ill adults, but not in rescue conditions.

KW - Critical care medicine

KW - Mechanical ventilation

KW - Extubation failure

KW - High-flow nasal cannula

KW - FLOW NASAL CANNULA

KW - POSITIVE-PRESSURE VENTILATION

KW - MECHANICAL VENTILATION

KW - PREVENT REINTUBATION

KW - CONTROLLED-TRIALS

KW - AIRWAY PRESSURE

KW - OXYGEN-THERAPY

KW - RE-INTUBATION

KW - FAILURE

KW - CARE

U2 - 10.1007/s00134-021-06581-1

DO - 10.1007/s00134-021-06581-1

M3 - Review

C2 - 34825256

VL - 48

SP - 137

EP - 147

JO - European Journal of Intensive Care Medicine

JF - European Journal of Intensive Care Medicine

SN - 0935-1701

ER -