Abstract
BackgroundAlthough non-invasive respiratory management strategies have been implemented to avoid intubation, patients with de novo acute hypoxaemic respiratory failure (AHRF) are high risk of treatment failure. In the previous meta-analyses, the effect of non-invasive ventilation was not evaluated according to ventilation modes in those patients. Furthermore, no meta-analyses comparing non-invasive respiratory management strategies with invasive mechanical ventilation (IMV) have been reported. We performed a network meta-analysis to compare the efficacy of non-invasive ventilation according to ventilation modes with high-flow nasal oxygen (HFNO), standard oxygen therapy (SOT), and IMV in adult patients with AHRF.MethodsThe Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and Ichushi databases were searched. Studies including adults with AHRF and randomized controlled trials (RCTs) comparing two different respiratory management strategies (continuous positive airway pressure (CPAP), pressure support ventilation (PSV), HFNO, SOT, or IMV) were reviewed.ResultsWe included 25 RCTs (3,302 participants: 27 comparisons). Using SOT as the reference, CPAP (risk ratio [RR] 0.55; 95% confidence interval [CI] 0.31–0.95; very low certainty) was associated significantly with a lower risk of mortality. Compared with SOT, PSV (RR 0.81; 95% CI 0.62–1.06; low certainty) and HFNO (RR 0.90; 95% CI 0.65–1.25; very low certainty) were not associated with a significantly lower risk of mortality. Compared with IMV, no non-invasive respiratory management was associated with a significantly lower risk of mortality, although all certainties of evidence were very low. The probability of being best in reducing short-term mortality among all possible interventions was higher for CPAP, followed by PSV and HFNO; IMV and SOT were tied for the worst (surface under the cumulative ranking curve value: 93.2, 65.0, 44.1, 23.9, and 23.9, respectively).ConclusionsWhen performing non-invasive ventilation among patients with de novo AHRF, it is important to avoid excessive tidal volume and lung injury. Although pressure support is needed for some of these patients, it should be applied with caution because this may lead to excessive tidal volume and lung injury.Trial registration protocols.io (Protocol integer ID 49375, April 23, 2021). https://doi.org/10.17504/protocols.io.buf7ntrn.
Highlights
Non-invasive respiratory management strategies have been implemented to avoid intubation, patients with de novo acute hypoxaemic respiratory failure (AHRF) are high risk of treatment failure
While non-invasive ventilation has been reported to be used in 15% of patients with acute respiratory distress syndrome (ARDS), it may be associated with higher intensive care unit (ICU) mortality, especially in patients with severe hypoxaemia [4]
The probability of being the best in reducing short-term mortality among all possible interventions was higher for continuous positive airway pressure (CPAP), followed by Pressure support ventilation (PSV) and high-flow nasal oxygen (HFNO); invasive mechanical ventilation (IMV) and standard oxygen therapy (SOT) tied for the worst (Table 2; Additional file 1: Figure S3)
Summary
Non-invasive respiratory management strategies have been implemented to avoid intubation, patients with de novo acute hypoxaemic respiratory failure (AHRF) are high risk of treatment failure. No meta-analyses comparing non-invasive respiratory management strategies with invasive mechanical ventilation (IMV) have been reported. We performed a network meta-analysis to compare the efficacy of non-invasive ventilation according to ventilation modes with high-flow nasal oxygen (HFNO), standard oxygen therapy (SOT), and IMV in adult patients with AHRF. Non-invasive ventilation is recommended to reduce the risk of endotracheal intubation and mortality in patients with AHRF, especially due to cardiopulmonary oedema [2]. When implementing noninvasive respiratory management strategies in patients with AHRF, we need to consider the cause of the respiratory failure, especially whether it was an established disease for efficacy of non-invasive ventilation including cardiopulmonary oedema or not. Noninvasive ventilation is not recommended in patients with de novo AHRF [6], and the efficacy of the HFNO has not been consistent among these patients [7, 8]
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