Non-invasive weaning from ventilation reduces mortality, ventilator-associated pneumonia, and length of stay in intubated adults

Abstract

To review the evidence as to whether early extubation with immediate application of non-invasive ventilation reduces mortality and ventilator-associated pneumonia and improves other outcomes in criticallyill adults receiving invasive ventilation. Medline, Embase, CENTRAL, searched up to April, 2008. This search was supplemented by hand-searching of conference proceeding and citation tracking. Randomised and quasi-randomised controlled trials involving adults with respiratory failure who required invasive ventilation for at least 24 hours in which extubation with immediate application of noninvasive ventilation was compared to continued invasive weaning. Outcome measures were mortality, ventilatorassociated pneumonia, weaning failure, length of stay in intensive care or hospital, total duration of ventilation (invasive and non-invasive), duration of ventilation related to weaning (after randomisation), duration of invasive-only ventilation, adverse events (arrhythmia, reintubation, tracheostomy), and quality of life. Two reviewers extracted data and discrepancies were resolved by consensus and arbitration. Methodological quality was assessed. Of 1368 studies identified by the initial search, 12 studies with a total of 530 patients met the selection criteria and were included in the review. All included studies were of moderate to high quality according to the reviewers’ criteria. Based on the quantitative pooling of the available data from these trials, there was a statistically significant difference in mortality in favour of non-invasive weaning, relative risk 0.55 (95% CI 0.38 to 0.79). Non-invasive weaning also significantly reduced ventilator-associated pneumonia (relative risk 0.29, 95% CI 0.19 to 0.45), length of stay in the intensive care unit (by 6 days, 95% CI 4 to 9) and in the hospital (by 7 days, 95% CI 4 to 11), total duration of ventilation (by 6 days, 95% CI 2 to 9), duration of invasive ventilation (by 8 days, 95% CI 4 to 11), and tracheostomy (relative risk 0.16, 95% CI 0.04 to 0.75). The remaining secondary outcomes did not differ significantly. None of the included studies measured quality of life. Non-invasive ventilation facilitates weaning and has substantial clinical benefits in adults with respiratory failure who require invasive ventilation.