Association of Non-Invasive Respiratory Support with Mortality and Intubation Rates in Acute Respiratory Failure: A Systematic Network Meta-Analysis

Abstract

Background: Non-invasive respiratory support devices may reduce the tracheal intubation rate compared with conventional oxygen therapy (COT). To date, few studies have compared high-flow nasal cannula (HFNC) use with non-invasive positive-pressure ventilation(NPPV). We conducted a network meta-analysis (NMA) to compare the effectiveness of three respiratory support devices in patients with acute respiratory failure. Methods: The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and Ichushi databases were searched. Adults ≥16 years of age with acute hypoxic respiratory failure and randomised controlled trials that compared two different respiratory support devices(COT,NPPV, or HFNC) before tracheal intubation were included. NMA was performed using a frequentist-based approach with multivariate random effects meta-analysis. The meta-analysis was performed using the GRADE Working Group Approach for an NMA. The primary outcome was short-term mortality, and the secondary outcome was the rate of intubation. Findings: Among 5,093 records, 25 studies (4,372 patients) were included. Compared with COT, NPPV and HFNC tended to reduce mortality (relative risk, 0·88 and 0·92; 95% confidence interval 0·76–1.01 and 0·80–1·07; low and moderate certainties, respectively); however, a significantly lower risk of endotracheal intubation(0·81 and 0·79; 0·71–0·91 and 0·69–0·91; low and moderate certainty, respectively) was observed. There were no significant differences in short-term mortality or endotracheal intubation (0·95 and 1·02;0·78–1·16 and0·86–1·20; respectively; both low certainty) for NPPV and HFNC use. Interpretation: NPPV and HFNC are associated with decreased endotracheal intubation risk, but there are no significant differences in short-term mortality. Funding: None. Declaration of Interests: The authors declare no competing interests.