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Comparison 1 NIV versus other methods of airway clearance (chest physiotherapy including directed cough or PEP), Outcome 1 Lung function ‐ chest physiotherapy including directed cough.
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Analysis 1.1

Comparison 1 NIV versus other methods of airway clearance (chest physiotherapy including directed cough or PEP), Outcome 1 Lung function ‐ chest physiotherapy including directed cough.

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Comparison 1 NIV versus other methods of airway clearance (chest physiotherapy including directed cough or PEP), Outcome 2 Lung function ‐ chest physiotherapy including PEP.
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Analysis 1.2

Comparison 1 NIV versus other methods of airway clearance (chest physiotherapy including directed cough or PEP), Outcome 2 Lung function ‐ chest physiotherapy including PEP.

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Comparison 1 NIV versus other methods of airway clearance (chest physiotherapy including directed cough or PEP), Outcome 3 Respiratory muscle strength.
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Analysis 1.3

Comparison 1 NIV versus other methods of airway clearance (chest physiotherapy including directed cough or PEP), Outcome 3 Respiratory muscle strength.

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Comparison 1 NIV versus other methods of airway clearance (chest physiotherapy including directed cough or PEP), Outcome 4 Airway resistance % predicted.
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Analysis 1.4

Comparison 1 NIV versus other methods of airway clearance (chest physiotherapy including directed cough or PEP), Outcome 4 Airway resistance % predicted.

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Comparison 1 NIV versus other methods of airway clearance (chest physiotherapy including directed cough or PEP), Outcome 5 Oxygen saturation during airway clearance (*SpO2 mean).
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Analysis 1.5

Comparison 1 NIV versus other methods of airway clearance (chest physiotherapy including directed cough or PEP), Outcome 5 Oxygen saturation during airway clearance (*SpO2 mean).

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Comparison 1 NIV versus other methods of airway clearance (chest physiotherapy including directed cough or PEP), Outcome 6 Oxygen saturation during airway clearance (change in SpO2 during treatment).
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Analysis 1.6

Comparison 1 NIV versus other methods of airway clearance (chest physiotherapy including directed cough or PEP), Outcome 6 Oxygen saturation during airway clearance (change in SpO2 during treatment).

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Comparison 1 NIV versus other methods of airway clearance (chest physiotherapy including directed cough or PEP), Outcome 7 Oxygen saturation after airway clearance (SpO2) ‐ chest physiotherapy including directed cough.
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Analysis 1.7

Comparison 1 NIV versus other methods of airway clearance (chest physiotherapy including directed cough or PEP), Outcome 7 Oxygen saturation after airway clearance (SpO2) ‐ chest physiotherapy including directed cough.

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Comparison 1 NIV versus other methods of airway clearance (chest physiotherapy including directed cough or PEP), Outcome 8 Oxygen saturation after airway clearance (SpO2) ‐ chest physiotherapy including PEP.
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Analysis 1.8

Comparison 1 NIV versus other methods of airway clearance (chest physiotherapy including directed cough or PEP), Outcome 8 Oxygen saturation after airway clearance (SpO2) ‐ chest physiotherapy including PEP.

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Comparison 1 NIV versus other methods of airway clearance (chest physiotherapy including directed cough or PEP), Outcome 9 Sputum wet weight ‐ chest physiotherapy including directed cough.
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Analysis 1.9

Comparison 1 NIV versus other methods of airway clearance (chest physiotherapy including directed cough or PEP), Outcome 9 Sputum wet weight ‐ chest physiotherapy including directed cough.

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Comparison 1 NIV versus other methods of airway clearance (chest physiotherapy including directed cough or PEP), Outcome 10 Sputum wet weight ‐ chest physiotherapy including PEP.
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Analysis 1.10

Comparison 1 NIV versus other methods of airway clearance (chest physiotherapy including directed cough or PEP), Outcome 10 Sputum wet weight ‐ chest physiotherapy including PEP.

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Comparison 1 NIV versus other methods of airway clearance (chest physiotherapy including directed cough or PEP), Outcome 11 Sputum dry weight ‐ chest physiotherapy including directed cough.
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Analysis 1.11

Comparison 1 NIV versus other methods of airway clearance (chest physiotherapy including directed cough or PEP), Outcome 11 Sputum dry weight ‐ chest physiotherapy including directed cough.

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Comparison 1 NIV versus other methods of airway clearance (chest physiotherapy including directed cough or PEP), Outcome 12 Sputum dry weight ‐ chest physiotherapy including PEP.
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Analysis 1.12

Comparison 1 NIV versus other methods of airway clearance (chest physiotherapy including directed cough or PEP), Outcome 12 Sputum dry weight ‐ chest physiotherapy including PEP.

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Comparison 1 NIV versus other methods of airway clearance (chest physiotherapy including directed cough or PEP), Outcome 13 Breathlessness.
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Analysis 1.13

Comparison 1 NIV versus other methods of airway clearance (chest physiotherapy including directed cough or PEP), Outcome 13 Breathlessness.

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Comparison 2 NIV in overnight ventilation compared to oxygen, Outcome 1 Lung function during sleep.
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Analysis 2.1

Comparison 2 NIV in overnight ventilation compared to oxygen, Outcome 1 Lung function during sleep.

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Comparison 2 NIV in overnight ventilation compared to oxygen, Outcome 2 Respiratory rate during sleep.
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Analysis 2.2

Comparison 2 NIV in overnight ventilation compared to oxygen, Outcome 2 Respiratory rate during sleep.

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Comparison 2 NIV in overnight ventilation compared to oxygen, Outcome 3 Total sleep time (TST).
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Analysis 2.3

Comparison 2 NIV in overnight ventilation compared to oxygen, Outcome 3 Total sleep time (TST).

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Comparison 2 NIV in overnight ventilation compared to oxygen, Outcome 4 REM sleep architecture.
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Analysis 2.4

Comparison 2 NIV in overnight ventilation compared to oxygen, Outcome 4 REM sleep architecture.

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Comparison 2 NIV in overnight ventilation compared to oxygen, Outcome 5 Sleep latency.
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Analysis 2.5

Comparison 2 NIV in overnight ventilation compared to oxygen, Outcome 5 Sleep latency.

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Comparison 2 NIV in overnight ventilation compared to oxygen, Outcome 6 Nocturnal oxygen saturation.
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Analysis 2.6

Comparison 2 NIV in overnight ventilation compared to oxygen, Outcome 6 Nocturnal oxygen saturation.

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Comparison 2 NIV in overnight ventilation compared to oxygen, Outcome 7 Nocturnal oxygen saturation.
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Analysis 2.7

Comparison 2 NIV in overnight ventilation compared to oxygen, Outcome 7 Nocturnal oxygen saturation.

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Comparison 2 NIV in overnight ventilation compared to oxygen, Outcome 8 Nocturnal TcCO2.
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Analysis 2.8

Comparison 2 NIV in overnight ventilation compared to oxygen, Outcome 8 Nocturnal TcCO2.

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Comparison 2 NIV in overnight ventilation compared to oxygen, Outcome 9 Nocturnal TcCO2.
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Analysis 2.9

Comparison 2 NIV in overnight ventilation compared to oxygen, Outcome 9 Nocturnal TcCO2.

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Comparison 2 NIV in overnight ventilation compared to oxygen, Outcome 10 Hypopneas.
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Analysis 2.10

Comparison 2 NIV in overnight ventilation compared to oxygen, Outcome 10 Hypopneas.

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Comparison 3 NIV in overnight ventilation compared to room air, Outcome 1 CFQoL chest symptom score.
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Analysis 3.1

Comparison 3 NIV in overnight ventilation compared to room air, Outcome 1 CFQoL chest symptom score.

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Comparison 3 NIV in overnight ventilation compared to room air, Outcome 2 CFQoL transitional dyspnea index score.
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Analysis 3.2

Comparison 3 NIV in overnight ventilation compared to room air, Outcome 2 CFQoL transitional dyspnea index score.

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Comparison 3 NIV in overnight ventilation compared to room air, Outcome 3 Lung function during sleep.
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Analysis 3.3

Comparison 3 NIV in overnight ventilation compared to room air, Outcome 3 Lung function during sleep.

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Comparison 3 NIV in overnight ventilation compared to room air, Outcome 4 Respiratory rate during sleep.
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Analysis 3.4

Comparison 3 NIV in overnight ventilation compared to room air, Outcome 4 Respiratory rate during sleep.

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Comparison 3 NIV in overnight ventilation compared to room air, Outcome 5 Exercise performance ‐modified shuttle walk test.
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Analysis 3.5

Comparison 3 NIV in overnight ventilation compared to room air, Outcome 5 Exercise performance ‐modified shuttle walk test.

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Comparison 3 NIV in overnight ventilation compared to room air, Outcome 6 Total sleep time (TST).
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Analysis 3.6

Comparison 3 NIV in overnight ventilation compared to room air, Outcome 6 Total sleep time (TST).

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Comparison 3 NIV in overnight ventilation compared to room air, Outcome 7 REM sleep architecture.
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Analysis 3.7

Comparison 3 NIV in overnight ventilation compared to room air, Outcome 7 REM sleep architecture.

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Comparison 3 NIV in overnight ventilation compared to room air, Outcome 8 Sleep latency.
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Analysis 3.8

Comparison 3 NIV in overnight ventilation compared to room air, Outcome 8 Sleep latency.

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Comparison 3 NIV in overnight ventilation compared to room air, Outcome 9 Nocturnal oxygen saturation.
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Analysis 3.9

Comparison 3 NIV in overnight ventilation compared to room air, Outcome 9 Nocturnal oxygen saturation.

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Comparison 3 NIV in overnight ventilation compared to room air, Outcome 10 Nocturnal oxygen saturation.
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Analysis 3.10

Comparison 3 NIV in overnight ventilation compared to room air, Outcome 10 Nocturnal oxygen saturation.

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Comparison 3 NIV in overnight ventilation compared to room air, Outcome 11 Nocturnal TcCO2.
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Analysis 3.11

Comparison 3 NIV in overnight ventilation compared to room air, Outcome 11 Nocturnal TcCO2.

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Comparison 3 NIV in overnight ventilation compared to room air, Outcome 12 Nocturnal TcCO2.
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Analysis 3.12

Comparison 3 NIV in overnight ventilation compared to room air, Outcome 12 Nocturnal TcCO2.

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Comparison 3 NIV in overnight ventilation compared to room air, Outcome 13 Hypopneas.
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Analysis 3.13

Comparison 3 NIV in overnight ventilation compared to room air, Outcome 13 Hypopneas.

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Table 1. List of abbreviations

Abbreviation

Definition

Explanation

CF

cystic fibrosis

COPD

chronic obstructive pulmonary disease

CPAP

continuous positive airway pressure

a system that maintains a positive pressure in the circuitry and airways throughout inspiration and expiration

CPT

chest physiotherapy

FEF25‐75

flow rate between 25 and 75% of maximal expiration

FEV1

forced expiratory volume in 1 second

FRC

functional residual capacity

resting volume of the lungs

FVC

forced vital capacity

total volume of air expired during a forced expiration following a full inspiration

MEF50

maximal expiratory flow with 50% of vital capacity remaining in the lung

mSpO2

mean oxygen saturation

nadirSpO2

the largest fall expressed in the absolute value of SpO2

NIV

non‐invasive ventilation

NREM

non‐rapid eye movement

a phase during sleep

PaCO2

partial pressure of carbon dioxide in arterial blood

PaO2

partial pressure of oxygen in arterial blood

PEP

positive expiratory pressure

an airway clearance technique

PSV

pressure support ventilation

RDI

respiratory disturbance index

REM

rapid eye movement

a phase during sleep

RR

respiratory rate

SaO2

saturation of haemoglobin with oxygen in arterial blood

SpO2

saturation of haemoglobin with oxygen using pulse oximetry

*SpO2 max

the largest fall expressed as the difference with the SpO2 just before the manoeuvre

*SpO2 mean

the mean of *SpO2 max during the whole chest physiotherapy period

TcCO2

transcutaneous carbon dioxide

TLC

total lung capacity

total volume of air in lungs following a maximum inspiration

TST

total sleep time

VI

minute ventilation

VT

tidal volume

volume air inspired or expired during normal breathing

IPAP

inspiratory positive airway pressure

PIMax

inspiratory respiratory muscle strength

PEMax

expiratory respiratory muscle strength
Figures and Tables -
Table 1. List of abbreviations
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Comparison 1. NIV versus other methods of airway clearance (chest physiotherapy including directed cough or PEP)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Lung function ‐ chest physiotherapy including directed cough Show forest plot

3

Std. Mean Difference (IV, Fixed, 95% CI)

Subtotals only

1.1 FEV1

3

118

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.05 [‐0.41, 0.31]

1.2 FVC

3

118

Std. Mean Difference (IV, Fixed, 95% CI)

0.02 [‐0.35, 0.38]

1.3 FEF25‐75

3

118

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.03 [‐0.39, 0.33]

2 Lung function ‐ chest physiotherapy including PEP Show forest plot

3

Std. Mean Difference (IV, Fixed, 95% CI)

Subtotals only

2.1 FEV1

3

118

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.06 [‐0.43, 0.30]

2.2 FVC

3

118

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.01 [‐0.37, 0.35]

2.3 FEF25‐75

3

118

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.00 [‐0.36, 0.36]

3 Respiratory muscle strength Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

3.1 PImax

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.2 PEmax

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

4 Airway resistance % predicted Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

5 Oxygen saturation during airway clearance (*SpO2 mean) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

6 Oxygen saturation during airway clearance (change in SpO2 during treatment) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

7 Oxygen saturation after airway clearance (SpO2) ‐ chest physiotherapy including directed cough Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

8 Oxygen saturation after airway clearance (SpO2) ‐ chest physiotherapy including PEP Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

9 Sputum wet weight ‐ chest physiotherapy including directed cough Show forest plot

3

118

Mean Difference (IV, Fixed, 95% CI)

‐0.69 [‐3.06, 1.67]

10 Sputum wet weight ‐ chest physiotherapy including PEP Show forest plot

3

118

Mean Difference (IV, Fixed, 95% CI)

‐1.54 [‐3.96, 0.89]

11 Sputum dry weight ‐ chest physiotherapy including directed cough Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

12 Sputum dry weight ‐ chest physiotherapy including PEP Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

13 Breathlessness Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only
Figures and Tables -
Comparison 1. NIV versus other methods of airway clearance (chest physiotherapy including directed cough or PEP)
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Comparison 2. NIV in overnight ventilation compared to oxygen

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Lung function during sleep Show forest plot

1

WMD (Fixed, 95% CI)

Subtotals only

1.1 VI while awake

1

WMD (Fixed, 95% CI)

0.49 [‐0.43, 1.41]

1.2 VI during REM

1

WMD (Fixed, 95% CI)

1.48 [0.74, 2.22]

1.3 VI during NREM

1

WMD (Fixed, 95% CI)

0.49 [‐0.29, 1.27]

1.4 VT while awake

1

WMD (Fixed, 95% CI)

0.03 [‐0.03, 0.09]

1.5 VT during REM

1

WMD (Fixed, 95% CI)

0.08 [0.04, 0.12]

1.6 VT during NREM

1

WMD (Fixed, 95% CI)

0.03 [0.01, 0.05]

2 Respiratory rate during sleep Show forest plot

1

WMD (Fixed, 95% CI)

Subtotals only

2.1 RR while awake

1

WMD (Fixed, 95% CI)

‐0.33 [‐3.33, 2.67]

2.2 RR during REM

1

WMD (Fixed, 95% CI)

‐1.84 [‐3.25, ‐0.43]

2.3 RR during NREM

1

WMD (Fixed, 95% CI)

‐1.15 [‐2.48, 0.18]

3 Total sleep time (TST) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

4 REM sleep architecture Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

4.1 REM

1

12

Mean Difference (IV, Fixed, 95% CI)

‐13.0 [‐43.25, 17.25]

4.2 REM %TST

1

12

Mean Difference (IV, Fixed, 95% CI)

‐3.0 [‐9.88, 3.88]

5 Sleep latency Show forest plot

2

38

Mean Difference (IV, Fixed, 95% CI)

2.93 [‐0.32, 6.19]

6 Nocturnal oxygen saturation Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

6.1 Mean SpO2 REM

1

12

Mean Difference (IV, Fixed, 95% CI)

‐2.0 [‐4.88, 0.88]

6.2 Mean SpO2 NREM

1

12

Mean Difference (IV, Fixed, 95% CI)

‐1.0 [‐2.79, 0.79]

7 Nocturnal oxygen saturation Show forest plot

1

WMD (Fixed, 95% CI)

Subtotals only

7.1 Percentage TST SpO2>90%

1

WMD (Fixed, 95% CI)

‐2.54 [‐9.59, 4.50]

7.2 Percentage REM SpO2>90%

1

WMD (Fixed, 95% CI)

0.65 [‐8.94, 10.25]

7.3 Percentage NREM SpO2>90%

1

WMD (Fixed, 95% CI)

‐0.84 [‐7.95, 6.26]

8 Nocturnal TcCO2 Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

8.1 TcCO2 during REM

1

12

Mean Difference (IV, Fixed, 95% CI)

‐1.90 [‐2.55, ‐1.25]

8.2 TcCO2 during NREM

1

12

Mean Difference (IV, Fixed, 95% CI)

‐1.40 [‐2.19, ‐0.61]

9 Nocturnal TcCO2 Show forest plot

1

WMD (Fixed, 95% CI)

Subtotals only

9.1 Mean change TcCO2 NREM to REM

1

WMD (Fixed, 95% CI)

‐2.60 [‐4.05, ‐1.16]

9.2 Maximum TcCO2 on each night

1

WMD (Fixed, 95% CI)

‐2.08 [‐10.64, 6.48]

10 Hypopneas Show forest plot

1

Relative rate (Fixed, 95% CI)

0.02 [0.01, 0.06]
Figures and Tables -
Comparison 2. NIV in overnight ventilation compared to oxygen
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Comparison 3. NIV in overnight ventilation compared to room air

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 CFQoL chest symptom score Show forest plot

1

WMD (Fixed, 95% CI)

Subtotals only

2 CFQoL transitional dyspnea index score Show forest plot

1

WMD (Fixed, 95% CI)

Subtotals only

3 Lung function during sleep Show forest plot

1

WMD (Fixed, 95% CI)

Subtotals only

3.1 VI while awake

1

WMD (Fixed, 95% CI)

0.88 [‐0.20, 1.95]

3.2 VI during REM

1

WMD (Fixed, 95% CI)

1.56 [0.05, 3.07]

3.3 VI during NREM

1

WMD (Fixed, 95% CI)

1.04 [0.37, 1.71]

3.4 VT while awake

1

WMD (Fixed, 95% CI)

0.06 [0.00, 0.12]

3.5 VT during REM

1

WMD (Fixed, 95% CI)

0.1 [0.04, 0.16]

3.6 VT during NREM

1

WMD (Fixed, 95% CI)

0.05 [‐0.01, 0.11]

4 Respiratory rate during sleep Show forest plot

1

WMD (Fixed, 95% CI)

Subtotals only

4.1 RR while awake

1

WMD (Fixed, 95% CI)

‐0.71 [‐3.45, 2.03]

4.2 RR during REM

1

WMD (Fixed, 95% CI)

‐2.64 [‐3.70, ‐1.58]

4.3 RR during NREM

1

WMD (Fixed, 95% CI)

‐0.83 [‐3.14, 1.48]

5 Exercise performance ‐modified shuttle walk test Show forest plot

1

WMD (Fixed, 95% CI)

Subtotals only

6 Total sleep time (TST) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

7 REM sleep architecture Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

7.1 REM

1

12

Mean Difference (IV, Fixed, 95% CI)

10.0 [‐13.37, 33.37]

7.2 REM %TST

1

12

Mean Difference (IV, Fixed, 95% CI)

3.00 [‐1.67, 7.67]

8 Sleep latency Show forest plot

2

38

Mean Difference (IV, Fixed, 95% CI)

‐2.63 [‐7.37, 2.11]

9 Nocturnal oxygen saturation Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

9.1 Mean SpO2 REM

1

12

Mean Difference (IV, Fixed, 95% CI)

9.0 [2.91, 15.09]

9.2 Mean SpO2 NREM

1

12

Mean Difference (IV, Fixed, 95% CI)

5.0 [0.69, 9.31]

10 Nocturnal oxygen saturation Show forest plot

1

WMD (Fixed, 95% CI)

Subtotals only

10.1 Percentage TST SpO2 >90%

1

WMD (Fixed, 95% CI)

27.58 [7.83, 47.33]

10.2 Percentage REM SpO2>90%

1

WMD (Fixed, 95% CI)

34.53 [15.00, 54.06]

10.3 Percentage NREM SpO2>90%

1

WMD (Fixed, 95% CI)

26.21 [6.24, 46.18]

11 Nocturnal TcCO2 Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

11.1 TcCO2 during REM

1

12

Mean Difference (IV, Fixed, 95% CI)

‐0.90 [‐1.62, ‐0.18]

11.2 TcCO2 during NREM

1

12

Mean Difference (IV, Fixed, 95% CI)

‐0.70 [‐1.15, ‐0.25]

12 Nocturnal TcCO2 Show forest plot

2

WMD (Fixed, 95% CI)

Subtotals only

12.1 Mean change TcCO2 NREM to REM

1

WMD (Fixed, 95% CI)

‐2.31 [‐3.30, ‐1.32]

12.2 Maximum TcCO2 on each night

2

WMD (Fixed, 95% CI)

‐8.49 [‐15.74, ‐1.23]

13 Hypopneas Show forest plot

1

Relative rate (Fixed, 95% CI)

0.02 [0.01, 0.05]
Figures and Tables -
Comparison 3. NIV in overnight ventilation compared to room air
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