Noninvasive respiratory support following extubation in critically ill adults: a systematic review and network meta-analysis,Intensive Care Medicine

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Noninvasive respiratory support following extubation in critically ill adults: a systematic review and network meta-analysis
Intensive Care Medicine ( IF 38.9 ) Pub Date : 2021-11-25 , DOI: 10.1007/s00134-021-06581-1
Shannon M Fernando _{1,

2} , Alexandre Tran _{1,

3,

4} , Behnam Sadeghirad _{5,

6} , Karen E A Burns _{6,

7,

8} , Eddy Fan _{7,

9,

10,

11} , Daniel Brodie _{12,

13} , Laveena Munshi _{7,

9,

10} , Ewan C Goligher _{7,

9,

10,

11} , Deborah J Cook _{6,

14} , Robert A Fowler _{7,

9,

15} , Margaret S Herridge _{7,

9,

10,

11} , Pierre Cardinal ₁ , Samir Jaber _{16,

17} , Morten Hylander Møller ₁₈ , Arnaud W Thille _{19,

20} , Niall D Ferguson _{7,

9,

10,

11} , Arthur S Slutsky _{7,

8} , Laurent J Brochard _{7,

8} , Andrew J E Seely _{1,

3,

4,

21} , Bram Rochwerg _{6,

14}

Affiliation

Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.
Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
Department of Surgery, University of Ottawa, Ottawa, ON, Canada.
School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
Department of Anesthesia, McMaster University, Hamilton, ON, Canada.
Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.
Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada.
Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada.
Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA.
Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA.
Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada.
Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
Hôpital Saint-Eloi, Centre Hospitalier Universitaire (CHU) Montpellier, PhyMedExp, INSERM, CNRS, Montpellier, France.
Département de Médecine Intensive et Réanimation, Centre Hospitalier Universitaire (CHU) Montpellier, PhyMedExp, INSERM, CNRS, Montpellier, France.
Department of Intensive Care, Copenhagen University Righospitalet, Copenhagen, Denmark.
Centre Hospitalier Universitaire de Poitiers, Médecine Intensive Réanimation, Poitiers, France.
INSERM Centre d'Investigation Clinique 1402, ALIVE, Université de Poitiers, Poitiers, France.
Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.

Purpose

Systematic review and network meta-analysis to investigate the efficacy of noninvasive respiratory strategies, including noninvasive positive pressure ventilation (NIPPV) and high-flow nasal cannula (HFNC), in reducing extubation failure among critically ill adults.

Methods

We searched databases from inception through October 2021 for randomized controlled trials (RCTs) evaluating noninvasive respiratory support therapies (NIPPV, HFNC, conventional oxygen therapy, or a combination of these) following extubation in critically ill adults. Two reviewers performed screening, full text review, and extraction independently. The primary outcome of interest was reintubation. We used GRADE to rate the certainty of our findings.

Results

We included 36 RCTs (6806 patients). Compared to conventional oxygen therapy, NIPPV (OR 0.65 [95% CI 0.52–0.82]) and HFNC (OR 0.63 [95% CI 0.45–0.87]) reduced reintubation (both moderate certainty). Sensitivity analyses showed that the magnitude of the effect was highest in patients with increased baseline risk of reintubation. As compared to HFNC, no difference in incidence of reintubation was seen with NIPPV (OR 1.04 [95% CI 0.78–1.38], low certainty). Compared to conventional oxygen therapy, neither NIPPV (OR 0.8 [95% CI 0.61–1.04], moderate certainty) or HFNC (OR 0.9 [95% CI 0.66–1.24], low certainty) reduced short-term mortality. Consistent findings were demonstrated across multiple subgroups, including high- and low-risk patients. These results were replicated when evaluating noninvasive strategies for prevention (prophylaxis), but not in rescue (application only after evidence of deterioration) situations.

Conclusions

Our findings suggest that both NIPPV and HFNC reduced reintubation in critically ill adults, compared to conventional oxygen therapy. NIPPV did not reduce incidence of reintubation when compared to HFNC. These findings support the preventative application of noninvasive respiratory support strategies to mitigate extubation failure in critically ill adults, but not in rescue conditions.

中文翻译：

危重成人拔管后的无创呼吸支持：系统评价和网络荟萃分析

目的

系统评价和网络荟萃分析旨在研究无创呼吸策略（包括无创正压通气（NIPPV）和高流量鼻插管（HFNC））在减少危重成人拔管失败方面的功效。

方法

我们检索了从开始到 2021 年 10 月的数据库，以评估危重成人拔管后无创呼吸支持疗法（NIPPV、HFNC、常规氧疗或这些疗法的组合）的随机对照试验 (RCT)。两名审稿人独立进行筛选、全文审阅和提取。感兴趣的主要结果是重新插管。我们使用 GRADE 来评估我们研究结果的确定性。

结果

我们纳入了 36 项随机对照试验（6806 名患者）。与传统氧疗相比，NIPPV（OR 0.65 [95% CI 0.52–0.82]）和 HFNC（OR 0.63 [95% CI 0.45–0.87]）减少了再插管（均为中等确定性）。敏感性分析显示，基线再插管风险增加的患者的影响程度最高。与 HFNC 相比，NIPPV 的再插管发生率没有差异（OR 1.04 [95% CI 0.78–1.38]，低确定性）。与传统氧疗相比，NIPPV（OR 0.8 [95% CI 0.61–1.04]，中等确定性）或 HFNC（OR 0.9 [95% CI 0.66–1.24]，低确定性）均未降低短期死亡率。多个亚组（包括高风险和低风险患者）的结果一致。这些结果在评估非侵入性预防策略时得到了重复，但在救援（仅在出现恶化证据后应用）情况下没有得到重复。