Importance Treatment with noninvasive oxygenation strategies such as noninvasive ventilation and high-flow nasal oxygen may be more effective than standard oxygen therapy alone in patients with acute hypoxemic respiratory failure. Objective To compare the association of noninvasive oxygenation strategies with mortality and endotracheal intubation in adults with acute hypoxemic respiratory failure. Data Sources The following bibliographic databases were searched from inception until April 2020: MEDLINE, Embase, PubMed, Cochrane Central Register of Controlled Trials, CINAHL, Web of Science, and LILACS. No limits were applied to language, publication year, sex, or race. Study Selection Randomized clinical trials enrolling adult participants with acute hypoxemic respiratory failure comparing high-flow nasal oxygen, face mask noninvasive ventilation, helmet noninvasive ventilation, or standard oxygen therapy. Data Extraction and Synthesis Two reviewers independently extracted individual study data and evaluated studies for risk of bias using the Cochrane Risk of Bias tool. Network meta-analyses using a bayesian framework to derive risk ratios (RRs) and risk differences along with 95% credible intervals (CrIs) were conducted. GRADE methodology was used to rate the certainty in findings. Main Outcomes and Measures The primary outcome was all-cause mortality up to 90 days. A secondary outcome was endotracheal intubation up to 30 days. Results Twenty-five randomized clinical trials (3804 participants) were included. Compared with standard oxygen, treatment with helmet noninvasive ventilation (RR, 0.40 [95% CrI, 0.24-0.63]; absolute risk difference, -0.19 [95% CrI, -0.37 to -0.09]; low certainty) and face mask noninvasive ventilation (RR, 0.83 [95% CrI, 0.68-0.99]; absolute risk difference, -0.06 [95% CrI, -0.15 to -0.01]; moderate certainty) were associated with a lower risk of mortality (21 studies [3370 patients]). Helmet noninvasive ventilation (RR, 0.26 [95% CrI, 0.14-0.46]; absolute risk difference, -0.32 [95% CrI, -0.60 to -0.16]; low certainty), face mask noninvasive ventilation (RR, 0.76 [95% CrI, 0.62-0.90]; absolute risk difference, -0.12 [95% CrI, -0.25 to -0.05]; moderate certainty) and high-flow nasal oxygen (RR, 0.76 [95% CrI, 0.55-0.99]; absolute risk difference, -0.11 [95% CrI, -0.27 to -0.01]; moderate certainty) were associated with lower risk of endotracheal intubation (25 studies [3804 patients]). The risk of bias due to lack of blinding for intubation was deemed high. Conclusions and Relevance In this network meta-analysis of trials of adult patients with acute hypoxemic respiratory failure, treatment with noninvasive oxygenation strategies compared with standard oxygen therapy was associated with lower risk of death. Further research is needed to better understand the relative benefits of each strategy.

中文翻译：

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无创氧合策略与成人急性低氧性呼吸衰竭全因死亡率的关联

对于急性低氧性呼吸衰竭患者，采用无创氧合策略（例如无创通气和高流量鼻氧）进行治疗可能比单独的标准氧疗更有效。目的比较无创氧合策略与成人急性低氧性呼吸衰竭死亡率和气管插管的相关性。数据来源 从开始到 2020 年 4 月检索了以下书目数据库：MEDLINE、Embase、PubMed、Cochrane Central Register of Controlled Trials、CINAHL、Web of Science 和 LILACS。对语言、出版年份、性别或种族没有限制。研究选择 纳入患有急性低氧性呼吸衰竭的成年参与者的随机临床试验，比较高流量鼻氧、面罩无创通气、头盔无创通气，或标准氧疗。数据提取和综合 两名评价员独立提取个体研究数据并使用 Cochrane 偏倚风险工具评估研究的偏倚风险。使用贝叶斯框架进行网络元分析来推导风险比 (RR) 和风险差异以及 95% 可信区间 (CrIs)。GRADE 方法用于评估结果的确定性。主要结果和措施 主要结果是长达 90 天的全因死亡率。次要结果是气管插管长达 30 天。结果 纳入了 25 项随机临床试验（3804 名参与者）。与标准氧气相比，头盔无创通气治疗（RR，0.40 [95% CrI，0.24-0.63]；绝对风险差，-0.19 [95% CrI，-0.37 至 -0.09]；低确定性）和面罩无创通气（RR，0.83 [95% CrI，0.68-0.99]；绝对风险差，-0.06 [95% CrI，-0.15 至 -0.01]；中等确定性）与较低的风险相关死亡率（21 项研究 [3370 名患者]）。头盔无创通气（RR，0.26 [95% CrI，0.14-0.46]；绝对风险差，-0.32 [95% CrI，-0.60 至 -0.16]；低确定性），面罩无创通气（RR，0.76 [95%] CrI，0.62-0.90]；绝对风险差，-0.12 [95% CrI，-0.25 至 -0.05]；中等确定性）和高流量鼻氧（RR，0.76 [95% CrI，0.55-0.99]）；绝对风险差异，-0.11 [95% CrI，-0.27 至 -0.01]；中等确定性）与较低的气管插管风险相关（25 项研究 [3804 名患者]）。由于插管缺乏盲法而导致的偏倚风险被认为很高。结论和相关性 在这项针对急性低氧性呼吸衰竭成年患者试验的网络荟萃分析中，与标准氧疗相比，无创氧合策略治疗与较低的死亡风险相关。需要进一步研究以更好地了解每种策略的相对优势。