Abstract
BackgroundNoninvasive ventilation (NIV) has proved to be a useful technique for breathing support. However, complications, discomfort, and failure of NIV were commonly caused by the mask. Therefore, the helmet was developed to improve performance and reduce complications; however, there has been no conclusive results on its effect until now. Thus, we performed a systematic review and meta-analysis to investigate the effect of NIV with a helmet versus the control strategy in patients with acute respiratory failure (ARF).MethodsWe searched Cochrane Library, PubMed, Ovid, and Embase databases and bibliographies of relevant articles published before June 2016. Randomized and case-control studies that adopted the helmet as an NIV interface and compared it with another interface were included. The primary outcomes were hospital mortality, intubation rate, and complications. The secondary outcomes included the length of intensive care unit (ICU) stay, gas exchange, and respiratory rate. Pooled odds ratios (ORs) and 95 % confidence intervals (CIs) were calculated by the Mantel-Haenszel method and mean difference by the inverse variance method in a fixed effect model or random effects model according to the heterogeneity.ResultsA total of 11 studies involving 621 patients were included. The overall hospital mortality was 17.53 % in the helmet NIV group versus 30.67 % in the control group. Use of the helmet was associated with lower hospital mortality (OR 0.43, 95 % CI 0.26 to 0.69, p = 0.0005), intubation rate (OR 0.32, 95 % CI 0.21 to 0.47, P < 0.00001), and complications (OR 0.6, 95 % CI 0.4 to 0.92, P = 0.02). In contrast, there was no significant difference in gas exchange and ICU stay (P >0.05). Subgroup analysis found the helmet reduced mortality mainly in hypoxemic ARF patients (P < 0.05) and a lower intubation rate was shown in randomized trials; fewer complications caused by the helmet might be restricted to case-control trials. Additionally, the effect of the helmet on PaCO2 was influenced by type of ARF and ventilation mode (P <0.00001).ConclusionNIV with a helmet was associated with reduced hospital mortality and intubation requirement. The helmet was as effective as the mask in gas exchange with no additional advantage. Large randomized controlled trials are needed to provide more robust evidence.
Highlights
Noninvasive ventilation (NIV) has proved to be a useful technique for breathing support
Literature search and study identification We found 310 articles according to the electronic search strategy and one additional study was added from the reference list of one article
We found that NIV with a helmet significantly reduced hospital mortality, tracheal intubation rate, and complications compared with the control techniques
Summary
Noninvasive ventilation (NIV) has proved to be a useful technique for breathing support. The helmet was developed to improve performance and reduce complications; there has been no conclusive results on its effect until now. We performed a systematic review and meta-analysis to investigate the effect of NIV with a helmet versus the control strategy in patients with acute respiratory failure (ARF). Noninvasive ventilation (NIV) has proved to be a useful technique for breathing support that improved gas exchange and reduced the need for intubation and mortality in patients with exacerbation of chronic obstructive pulmonary disease, acute cardiogenic pulmonary edema, and blunt chest trauma [1,2,3,4]. Whether NIV delivered by helmet could reduce the intubation rate and mortality was still causing controversy [15, 16], the effect on gas exchange was confusing. Some studies indicated NIV delivered by helmet could improve oxygenation further compared with a face mask [17, 18], while others showed there was no significant difference in oxygenation [19,20,21], and some studies even demonstrated helmet-induced carbon dioxide rebreathing [22]
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