Abstract
BackgroundRespiratory support has been increasingly used after extubation for the prevention of re-intubation and improvement of prognosis in critically ill medical patients. However, the optimal respiratory support method is still under debate. This network meta-analysis (NMA) aims to evaluate the comparative effectiveness of various respiratory support methods used for preventive purposes after scheduled extubation in critically ill medical patients.MethodsA systematic database search was performed from inception to December 19, 2019, for randomized controlled trials (RCTs) that compared a preventive use of different respiratory support methods, including conventional oxygen therapy (COT), noninvasive ventilation (NIV), high-flow oxygen therapy (HFOT), and combinational use of HFOT and NIV (HFOT+NIV), after planned extubation in adult critically ill medical patients. Study selection, data extraction, and quality assessments were performed in duplicate. The primary outcomes included re-intubation rate and short-term mortality.ResultsSeventeen RCTs comprising 3341 participants with 4 comparisons were included. Compared with COT, NIV significantly reduced the re-intubation rate [risk ratio (RR) 0.55, 95% confidence interval (CI) 0.39 to 0.77; moderate quality of evidence] and short-term mortality (RR 0.66, 95% CI 0.48 to 0.91; moderate quality of evidence). Compared to COT, HFOT had a beneficial effect on the re-intubation rate (RR 0.55, 95% CI 0.35 to 0.86; moderate quality of evidence) but no effect on short-term mortality (RR 0.79, 95% CI 0.56 to 1.12; low quality of evidence). No significant difference in the re-intubation rate or short-term mortality was found among NIV, HFOT, and HFOT+NIV. The treatment rankings based on the surface under the cumulative ranking curve (SUCRA) from best to worst for re-intubation rate were HFOT+NIV (95.1%), NIV (53.4%), HFOT (51.2%), and COT (0.3%), and the rankings for short-term mortality were NIV (91.0%), HFOT (54.3%), HFOT+NIV (43.7%), and COT (11.1%). Sensitivity analyses of trials with a high risk of extubation failure for the primary outcomes indicated that the SUCRA rankings were comparable to those of the primary analysis.ConclusionsAfter scheduled extubation, the preventive use of NIV is probably the most effective respiratory support method for comprehensively preventing re-intubation and short-term death in critically ill medical patients, especially those with a high risk of extubation failure.
Highlights
Respiratory support has been increasingly used after extubation for the prevention of re-intubation and improvement of prognosis in critically ill medical patients
Invasive mechanical ventilation (IMV) is universally recognized as a first-line therapy for rescuing acute respiratory failure. It is a life-saving treatment in nature, prolonged IMV is always accompanied by an increased risk of ventilator-associated pneumonia and lung injury [1, 2] and neurocognitive sequelae associated with prolonged sedation [3, 4], resulting in a longer duration of intensive care unit (ICU) stay and increased mortality [5, 6]
Conventional oxygen therapy (COT) can only deliver a maximum flow of oxygen (O2) of 15 L/min using the Venturi mask or reservoir mask [11], and the delivered fraction of inspired oxygen (FiO2) is unstable because the Fraction of inspired oxygen (FiO2) depends on the inspiratory flow, respiration rate, and tidal volume of patients in addition to the O2 flow [12]
Summary
Respiratory support has been increasingly used after extubation for the prevention of re-intubation and improvement of prognosis in critically ill medical patients. Invasive mechanical ventilation (IMV) is universally recognized as a first-line therapy for rescuing acute respiratory failure It is a life-saving treatment in nature, prolonged IMV is always accompanied by an increased risk of ventilator-associated pneumonia and lung injury [1, 2] and neurocognitive sequelae associated with prolonged sedation [3, 4], resulting in a longer duration of intensive care unit (ICU) stay and increased mortality [5, 6]. Noninvasive ventilation (NIV) and high-flow oxygen therapy (HFOT) have been increasingly used as alternative respiratory support methods in post-extubated patients Both NIV and HFOT are anticipated to prevent extubation failure and improve prognosis by delivering more stable FiO2 [12, 13], promoting alveolar recruitment and preventing alveolar collapse [14,15,16], and reducing the work of breathing [17, 18]
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