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Cochrane Database of Systematic Reviews

Noninvasive positive‐pressure ventilation as a weaning strategy for intubated adults with respiratory failure

Information

DOI:
https://doi.org/10.1002/14651858.CD004127.pub3Copy DOI
Database:
  1. Cochrane Database of Systematic Reviews
Version published:
  1. 09 December 2013see what's new
Type:
  1. Intervention
Stage:
  1. Review
Cochrane Editorial Group:
  1. Cochrane Emergency and Critical Care Group

Copyright:
  1. Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Authors

  • Karen EA Burns

    Correspondence to: Interdepartmental Division of Critical Care, Keenan Research Centre/Li Ka Shing Knowledge Institute, University of Toronto, Toronto, Canada

    [email protected]

    [email protected]

  • Maureen O Meade

    Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada

  • Azra Premji

    The University of Toronto, Toronto, Canada

  • Neill KJ Adhikari

    Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada

Contributions of authors

Karen Burns (KB): proposed the research question and title; designed the protocol; reviewed and retrieved relevant articles; assessed methodologic quality of retrieved articles; abstracted data as the primary review author; entered data; conducted the statistical analysis and prepared the final review.

Neill Adhikari (NA): reviewed and retrieved relevant articles; assessed methodologic quality of retrieved articles; abstracted data as the second review author and revised the final review for important intellectual content.

Azra Premji (AP): assisted in retrieving articles and updating the text of the review. Also revised the final review for methodologic quality and scientific integrity.

Maureen Meade (MM): adjudicated disagreements; supervised the methodologic integrity of the review; reviewed the manuscript for methodologic and scientific integrity.

Sources of support

Internal sources

  • New source of support, Other.

External sources

  • Dr Burns is the recipient of a Canadian Institutes of Health Research Clinician Scientist Phase 2 Award, Canada.

Declarations of interest

Karen EA Burns: none known.

Maureen O Meade: Dr Meade has received in‐kind support from industry in the form of equipment loans for use in the context of a multicentre clinical trial.

Azra Premji: none known.

Neill KJ Adhikari: none known.

Acknowledgements

We would like to thank the the Cochrane editorial team and our peer reviewers (Dr Harald Herkner, Professor Nathan Pace, Dr Felix Ram, Dr Andrew Jones, Dr Bronagh Blackwood, Dr Eddy Fan and Dr Andrew MacDuff) for their contributions to the review. We would also like to thank the authors of the primary research, who provided additional information pertinent to the design and outcomes of their respective clinical trials, and Dr Sean Keenan, who, although not able to participate in the updated review, provided advice regarding study selection. We thank Haibo Zhang, Haibo Qiu, Wei Ehr Cheng, Zhuxian Feng and Hanpo Yu for their assistance with translating and contacting authors to clarify publication and study design in earlier issues of this review.

Version history

Published

Title

Stage

Authors

Version

2013 Dec 09

Noninvasive positive‐pressure ventilation as a weaning strategy for intubated adults with respiratory failure

Review

Karen EA Burns, Maureen O Meade, Azra Premji, Neill KJ Adhikari

https://doi.org/10.1002/14651858.CD004127.pub3

2010 Aug 04

Noninvasive positive pressure ventilation as a weaning strategy for intubated adults with respiratory failure

Review

Karen EA Burns, Neill KJ Adhikari, Sean P Keenan, Maureen O Meade

https://doi.org/10.1002/14651858.CD004127.pub2

2003 Oct 20

Noninvasive positive pressure ventilation as a weaning strategy for intubated adults with respiratory failure

Review

Karen E. A. Burns, Neill K. J. Adhikari, Maureen O. Meade

https://doi.org/10.1002/14651858.CD004127

Notes

In the previously published protocol, as part of an a priori sensitivity analysis, we stated that we would assess the impact of the cause of respiratory failure (COPD vs non‐COPD) on (1) the proportion of weaning failures and (2) mortality. In the last version of this review, we identified two studies restricted to participants with COPD and three studies with mixed participant populations. In the absence of individual participant data, we compared studies restricted to COPD participants versus those with mixed participant populations. To explore for potential differences in response to NPPV, we compared studies enrolling at least 50% COPD participants versus those enrolling less than 50% COPD participants, in terms of mortality.

To search EMBASE, we used the following Emtree terms: respiratory failure (explode), positive end‐expiratory pressure (explode) and weaning (explode). In addition, we used the Emtag: artificial ventilation.

In the protocol, we stated that the MEDLINE search strategy would be limited to include the following publication types: clinical trials, controlled clinical trials, randomized controlled trials, multicenter studies and meta‐analyses. In the review, we did not limit the most recent literature search by publication type.

October 2013

Quality assessment

In this update, we evaluated and recorded the presence of true randomization and use of concealed allocation to minimize selection bias. Additionally, we evaluated reports of randomized trials for completeness of outcome data and selective outcomes reporting to assess for attrition and reporting biases, respectively.

Unlike in the previous review (Burns 2010), we did not include in our quality assessment the use of daily screening to identify participants capable of unassisted breathing; inclusion of predefined, permissive weaning criteria to identify weaning candidates (including but not limited to minute ventilation, tidal volume (VT), vital capacity, respiratory rate, rapid shallow breathing index, Glasgow Coma Scale, presence of spontaneous ventilatory efforts and a cough reflex, requirement for PEEP and ability to maintain arterial oxygen saturation above 90% on a fractional concentration of inspired oxygen (FiO2) of less than 0.50) and performance of spontaneous breathing trials (SBTs). We did not include assessment of the use of weaning protocols or guidelines (in both groups) and criteria for failure of prerandomization SBT, discontinuation of mechanical ventilation (in both groups) and extubation, reintubation due to poor reporting of these aspects of trial design and implementation and concerns over the reliability of efforts to acquire these details amidst language issues. We contacted study authors to ask them to describe specific features of their trials, including use of daily screening and a prerandomization SBT; however, we did not include them in the quality assessment in this update.

Summary of findings

We included in this update SoF tables for the outcomes of mortality, weaning failure, VAP and reintubation.

Exclusion criteria

We updated our exclusion criteria to exclude studies evaluating exclusively tracheostomized participants, as (1) tracheostomy was an outcome of this review, (2) these studies typically include a high proportion of participants undergoing prolonged mechanical ventilation and (3) application of the interventions could be different in the setting of a tracheostomy (e.g. participants randomly assigned to noninvasive weaning may meet criteria to return to invasive ventilation per tracheostomy and subsequently may be returned to noninvasive ventilation. Similarly, participants randomly assigned to invasive weaning may undergo a series of SBTs before extubation).

Keywords

MeSH

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Study flow diagram.
Figures and Tables -
Figure 1

Study flow diagram.

Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
Figures and Tables -
Figure 2

Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
Figures and Tables -
Figure 3

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.

Comparison 1 Noninvasive versus invasive weaning, Outcome 1 Mortality.
Figures and Tables -
Analysis 1.1

Comparison 1 Noninvasive versus invasive weaning, Outcome 1 Mortality.

Comparison 2 Noninvasive versus invasive weaning, Outcome 1 Weaning failure.
Figures and Tables -
Analysis 2.1

Comparison 2 Noninvasive versus invasive weaning, Outcome 1 Weaning failure.

Comparison 3 Noninvasive versus invasive weaning, Outcome 1 Nosocomial pneumonia.
Figures and Tables -
Analysis 3.1

Comparison 3 Noninvasive versus invasive weaning, Outcome 1 Nosocomial pneumonia.

Comparison 4 Noninvasive versus invasive weaning, Outcome 1 LOS ICU.
Figures and Tables -
Analysis 4.1

Comparison 4 Noninvasive versus invasive weaning, Outcome 1 LOS ICU.

Comparison 5 Noninvasive versus invasive weaning, Outcome 1 LOS hospital.
Figures and Tables -
Analysis 5.1

Comparison 5 Noninvasive versus invasive weaning, Outcome 1 LOS hospital.

Comparison 6 Noninvasive versus invasive weaning, Outcome 1 Average total duration of mechanical ventilatory support.
Figures and Tables -
Analysis 6.1

Comparison 6 Noninvasive versus invasive weaning, Outcome 1 Average total duration of mechanical ventilatory support.

Comparison 7 Noninvasive versus invasive weaning, Outcome 1 Average duration of ventilation related to weaning.
Figures and Tables -
Analysis 7.1

Comparison 7 Noninvasive versus invasive weaning, Outcome 1 Average duration of ventilation related to weaning.

Comparison 8 Noninvasive versus invasive weaning, Outcome 1 Duration of endotracheal mechanical ventilation.
Figures and Tables -
Analysis 8.1

Comparison 8 Noninvasive versus invasive weaning, Outcome 1 Duration of endotracheal mechanical ventilation.

Comparison 9 Noninvasive versus invasive weaning, Outcome 1 Reintubation.
Figures and Tables -
Analysis 9.1

Comparison 9 Noninvasive versus invasive weaning, Outcome 1 Reintubation.

Comparison 10 Noninvasive versus invasive weaning, Outcome 1 Arrhythmia.
Figures and Tables -
Analysis 10.1

Comparison 10 Noninvasive versus invasive weaning, Outcome 1 Arrhythmia.

Comparison 11 Noninvasive versus invasive weaning, Outcome 1 Tracheostomy.
Figures and Tables -
Analysis 11.1

Comparison 11 Noninvasive versus invasive weaning, Outcome 1 Tracheostomy.

Comparison 12 Sensitivity analysis: noninvasive versus invasive weaning, Outcome 1 Mortality excluding quasi‐randomized trial.
Figures and Tables -
Analysis 12.1

Comparison 12 Sensitivity analysis: noninvasive versus invasive weaning, Outcome 1 Mortality excluding quasi‐randomized trial.

Comparison 12 Sensitivity analysis: noninvasive versus invasive weaning, Outcome 2 Nosocomial pneumonia excluding quasi‐randomized trial.
Figures and Tables -
Analysis 12.2

Comparison 12 Sensitivity analysis: noninvasive versus invasive weaning, Outcome 2 Nosocomial pneumonia excluding quasi‐randomized trial.

Comparison 13 Noninvasive versus invasive weaning, Outcome 1 Mortality greater than or equal to 50% COPD versus less than 50% COPD.
Figures and Tables -
Analysis 13.1

Comparison 13 Noninvasive versus invasive weaning, Outcome 1 Mortality greater than or equal to 50% COPD versus less than 50% COPD.

Comparison 14 Noninvasive versus invasive weaning, Outcome 1 Weaning failure greater than or equal to 50% COPD.
Figures and Tables -
Analysis 14.1

Comparison 14 Noninvasive versus invasive weaning, Outcome 1 Weaning failure greater than or equal to 50% COPD.

Comparison 15 Noninvasive versus invasive weaning, Outcome 1 Weaning failure.
Figures and Tables -
Analysis 15.1

Comparison 15 Noninvasive versus invasive weaning, Outcome 1 Weaning failure.

Comparison 15 Noninvasive versus invasive weaning, Outcome 2 Nosocomial pneumonia.
Figures and Tables -
Analysis 15.2

Comparison 15 Noninvasive versus invasive weaning, Outcome 2 Nosocomial pneumonia.

Comparison 15 Noninvasive versus invasive weaning, Outcome 3 Average duration of ventilation related to weaning.
Figures and Tables -
Analysis 15.3

Comparison 15 Noninvasive versus invasive weaning, Outcome 3 Average duration of ventilation related to weaning.

Comparison 15 Noninvasive versus invasive weaning, Outcome 4 Reintubation.
Figures and Tables -
Analysis 15.4

Comparison 15 Noninvasive versus invasive weaning, Outcome 4 Reintubation.

Summary of findings for the main comparison. Noninvasive versus invasive weaning for intubated adults with respiratory failure

Noninvasive versus invasive weaning for intubated adults with respiratory failure

Patient or population: intubated adults with respiratory failure
Settings:
Intervention: noninvasive versus invasive weaning

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Noninvasive versus invasive weaning

MortalityCOPD

Study population

RR 0.36
(0.24 to 0.56)

632
(9 studies)

⊕⊕⊕⊝
moderate1

225 per 1000

81 per 1000
(54 to 126)

Moderate

200 per 1000

72 per 1000
(48 to 112)

Mortalitymixed

Study population

RR 0.81
(0.47 to 1.4)

362
(7 studies)

⊕⊕⊝⊝
low1

239 per 1000

194 per 1000
(112 to 335)

Moderate

270 per 1000

219 per 1000
(127 to 378)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio.

GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1Fewer than 300 events.

Test for subgroup differences (P = 0.02).

Figures and Tables -
Summary of findings for the main comparison. Noninvasive versus invasive weaning for intubated adults with respiratory failure
Summary of findings 2. Noninvasive versus invasive weaning for intubated adults with respiratory failure

Noninvasive versus invasive weaning for intubated adults with respiratory failure

Patient or population: patients with intubated adults with respiratory failure
Settings:
Intervention: Noninvasive versus invasive weaning

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Noninvasive versus invasive weaning

Weaning failure

Study population

RR 0.63
(0.42 to 0.96)

605
(8 studies)

⊕⊕⊕⊝
moderate1

362 per 1000

228 per 1000
(152 to 348)

Moderate

327 per 1000

206 per 1000
(137 to 314)

Nosocomial pneumonia

Study population

RR 0.25
(0.15 to 0.43)

953
(14 studies)

⊕⊕⊝⊝
low2

296 per 1000

74 per 1000
(44 to 127)

Moderate

307 per 1000

77 per 1000
(46 to 132)

Average duration of ventilation related to weaning

The mean average duration of ventilation related to weaning in the intervention groups was
0.25 lower
(2.06 lower to 1.56 higher)

645
(9 studies)

⊕⊕⊝⊝
low3,4,5

Reintubation

Study population

RR 0.65
(0.44 to 0.97)

789
(10 studies)

⊕⊕⊕⊝
moderate1

310 per 1000

202 per 1000
(137 to 301)

Moderate

286 per 1000

186 per 1000
(126 to 277)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Less than 300 events
2 RR 0.25 (95% CI 0.15 to 0.43)
3 Impact of heterogeneity was considerable (I2 =90%)
4 95% CI spans from a clinically important and significant increase or decrease
5 Uncertain if estimates include non‐survivors due to differential between group mortality (higher in control arm)

Figures and Tables -
Summary of findings 2. Noninvasive versus invasive weaning for intubated adults with respiratory failure
Table 1. Populations and interventions in studies of noninvasive ventilation in critically ill adults

Study

No of participants

Inclusion criteria (participants)

Inclusion criteria

(weaning eligibility)

Experimental strategy

Control strategy

Nava

1998

50

Exacerbation of COPD. Intubated for at least 36 to 48 hours

Simple weaning criteria, 1‐hour SBT failure

Noninvasive pressure support on conventional ventilator delivered with face mask

Invasive PS

Girault 1999

33

Acute‐on‐chronic respiratory failure (COPD, restrictive, or mixed populations). Intubated for at least 48 hours

Simple weaning criteria, 2‐hour SBT failure

Flow or pressure mode with nasal or face mask

Flow or pressure mode (PS)

Hill

2000

21

Acute respiratory failure

30‐minute SBT failure

NPPV using VPAP in ST‐A mode

Invasive PS

 

Chen

 2001

 

24

 

Exacerbation of COPD. Intubated for at least 48 to 60 hours. Saturation > 88% on FiO2 of 40%

 

Day 3+ weaning criteria

 

Bilevel NPPV (pressure mode)

 

Invasive PS

Ferrer 2003

43

Acute respiratory failure and persistent weaning failure. Intubated for at least 72 hours

Two‐hour SBT failure on 3 consecutive days

Bilevel NPPV in ST mode delivered with face or nasal mask

AC or invasive PS

Rabie Agmy

 2004

37

Exacerbation of COPD

Two‐hour SBT failure

NPPV (proportional assist in timed mode) delivered by face or nasal mask

Invasive PS

Wang 2004

28

COPD. Bronchopulmonary infection

PIC window

NPPV (pressure mode) delivered by mask (unspecified)

 

SIMV + PS

Zheng

2005

33

COPD. Severe pulmonary infection

PIC window

Bilevel NPPV (pressure mode) delivered by face or nasal mask

Invasive PS

Zou

2006

76

COPD with severe respiratory failure. Pulmonary infection

PIC window

Bilevel NPPV (pressure, ST mode) delivered by nasal or oronasal mask

SIMV + PS

Wang

2005

90

COPD with severe hypercapneic respiratory failure. Pneumonia or purulent bronchitis. Age < 85. Capable of self care in past year

PIC window

Bilevel NPPV (pressure mode)

SIMV + PS

Trevisan 2008

65

Invasively ventilated > 48 hours

30‐minute SBT failure

Bilevel NPPV (pressure mode) delivered by face mask

Invasive mechanical ventilation

Prasad 2009

30

COPD. Hypercapneic respiratory failure

Two‐hour SBT failure

Bilevel NPPV (pressure mode) delivered by full face mask

Invasive PS

Girault 2011

138

Chronic hypercapneic respiratory failure invasively ventilated for at least 48 hours

Two‐hour SBT failure

Noninvasive PS ± PEEP or bilevel NIV with face mask (initial choice)

Invasive PS with once‐daily SBT with T‐piece or PS ± PEEP

Rabie Agmy

2012

264

Acute‐on‐chronic exacerbation of COPD

 

Two‐hour SBT failure

 

NPPV (pressure, ST mode)

Invasive PS

Tawfeek

2012

42

Invasively ventilated for > 48 hours

 

Two‐hour SBT failure

 

Noninvasive PAV ventilation delivered by face mask

SIMV

Vaschetto 2012

20

Hypoxemic respiratory failure invasively ventilated for at least 48 hours

PS  with PEEP + inspiratory support, < 25 cm H2O

 

PEEP 8 to 13 cm H2O

 

PaO2/FiO2 200 to 300 mm Hg with FiO2< 0.6

Helmet NPPV

Invasive PS with SBT when P/F ratio > 250 mm Hg

COPD = chronic obstructive pulmonary disease; NPPV = noninvasive positive‐pressure ventilation; PS = pressure support; PEEP = positive end‐expiratory pressure; PIC = pulmonary infection control window; ST = spontaneous timed; AC = assist control; SIMV = synchronized intermittent mandatory ventilation; P/F ratio = ratio of arterial concentration of oxygen to fractional concentration of oxygen administered; SBT = spontaneous breathing trial; PAV = proportional assist ventilation.

Figures and Tables -
Table 1. Populations and interventions in studies of noninvasive ventilation in critically ill adults
Comparison 1. Noninvasive versus invasive weaning

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Mortality Show forest plot

16

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

1.1 COPD

9

632

Risk Ratio (M‐H, Random, 95% CI)

0.36 [0.24, 0.56]

1.2 Mixed

7

362

Risk Ratio (M‐H, Random, 95% CI)

0.81 [0.47, 1.40]

Figures and Tables -
Comparison 1. Noninvasive versus invasive weaning
Comparison 2. Noninvasive versus invasive weaning

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Weaning failure Show forest plot

8

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

1.1 COPD

3

351

Risk Ratio (M‐H, Random, 95% CI)

0.52 [0.36, 0.74]

1.2 Mixed

5

254

Risk Ratio (M‐H, Random, 95% CI)

0.73 [0.35, 1.51]

Figures and Tables -
Comparison 2. Noninvasive versus invasive weaning
Comparison 3. Noninvasive versus invasive weaning

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Nosocomial pneumonia Show forest plot

14

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

1.1 COPD

9

632

Risk Ratio (M‐H, Random, 95% CI)

0.22 [0.13, 0.37]

1.2 Mixed

5

321

Risk Ratio (M‐H, Random, 95% CI)

0.38 [0.15, 0.93]

Figures and Tables -
Comparison 3. Noninvasive versus invasive weaning
Comparison 4. Noninvasive versus invasive weaning

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 LOS ICU Show forest plot

13

Mean Difference (IV, Random, 95% CI)

Subtotals only

1.1 COPD

8

608

Mean Difference (IV, Random, 95% CI)

‐6.66 [‐9.41, ‐3.92]

1.2 Mixed

5

299

Mean Difference (IV, Random, 95% CI)

‐3.32 [‐6.78, 0.15]

Figures and Tables -
Comparison 4. Noninvasive versus invasive weaning
Comparison 5. Noninvasive versus invasive weaning

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 LOS hospital Show forest plot

10

Mean Difference (IV, Random, 95% CI)

Subtotals only

1.1 COPD

6

524

Mean Difference (IV, Random, 95% CI)

‐6.91 [‐10.83, ‐1.00]

1.2 Mixed

4

279

Mean Difference (IV, Random, 95% CI)

‐4.02 [‐9.41, 1.36]

Figures and Tables -
Comparison 5. Noninvasive versus invasive weaning
Comparison 6. Noninvasive versus invasive weaning

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Average total duration of mechanical ventilatory support Show forest plot

7

Mean Difference (IV, Random, 95% CI)

Subtotals only

1.1 COPD

5

277

Mean Difference (IV, Random, 95% CI)

‐5.77 [‐10.64, ‐0.91]

1.2 Mixed

2

108

Mean Difference (IV, Random, 95% CI)

‐5.20 [‐11.34, 0.93]

Figures and Tables -
Comparison 6. Noninvasive versus invasive weaning
Comparison 7. Noninvasive versus invasive weaning

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Average duration of ventilation related to weaning Show forest plot

9

Mean Difference (IV, Random, 95% CI)

Subtotals only

1.1 COPD

4

355

Mean Difference (IV, Random, 95% CI)

‐1.43 [‐3.12, 0.26]

1.2 Mixed

5

290

Mean Difference (IV, Random, 95% CI)

0.17 [‐4.01, 4.35]

Figures and Tables -
Comparison 7. Noninvasive versus invasive weaning
Comparison 8. Noninvasive versus invasive weaning

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Duration of endotracheal mechanical ventilation Show forest plot

12

Mean Difference (IV, Random, 95% CI)

Subtotals only

1.1 COPD

7

558

Mean Difference (IV, Random, 95% CI)

‐7.53 [‐11.47, ‐3.60]

1.2 Mixed

5

159

Mean Difference (IV, Random, 95% CI)

‐6.85 [‐10.75, ‐2.95]

Figures and Tables -
Comparison 8. Noninvasive versus invasive weaning
Comparison 9. Noninvasive versus invasive weaning

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Reintubation Show forest plot

10

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

1.1 COPD

3

430

Risk Ratio (M‐H, Random, 95% CI)

0.49 [0.35, 0.70]

1.2 Mixed

7

359

Risk Ratio (M‐H, Random, 95% CI)

0.82 [0.47, 1.43]

Figures and Tables -
Comparison 9. Noninvasive versus invasive weaning
Comparison 10. Noninvasive versus invasive weaning

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Arrhythmia Show forest plot

3

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

1.1 COPD

1

30

Risk Ratio (M‐H, Random, 95% CI)

2.0 [0.20, 19.78]

1.2 Mixed

2

171

Risk Ratio (M‐H, Random, 95% CI)

0.74 [0.26, 2.17]

Figures and Tables -
Comparison 10. Noninvasive versus invasive weaning
Comparison 11. Noninvasive versus invasive weaning

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Tracheostomy Show forest plot

7

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

1.1 COPD

1

264

Risk Ratio (M‐H, Random, 95% CI)

0.04 [0.00, 0.60]

1.2 Mixed

6

308

Risk Ratio (M‐H, Random, 95% CI)

0.23 [0.09, 0.57]

Figures and Tables -
Comparison 11. Noninvasive versus invasive weaning
Comparison 12. Sensitivity analysis: noninvasive versus invasive weaning

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Mortality excluding quasi‐randomized trial Show forest plot

15

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

2 Nosocomial pneumonia excluding quasi‐randomized trial Show forest plot

13

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

Figures and Tables -
Comparison 12. Sensitivity analysis: noninvasive versus invasive weaning
Comparison 13. Noninvasive versus invasive weaning

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Mortality greater than or equal to 50% COPD versus less than 50% COPD Show forest plot

16

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

1.1 Greater than or equal to 50% COPD

12

846

Risk Ratio (M‐H, Random, 95% CI)

0.47 [0.29, 0.76]

1.2 Less than 50% COPD

4

148

Risk Ratio (M‐H, Random, 95% CI)

0.86 [0.47, 1.58]

Figures and Tables -
Comparison 13. Noninvasive versus invasive weaning
Comparison 14. Noninvasive versus invasive weaning

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Weaning failure greater than or equal to 50% COPD Show forest plot

8

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

1.1 Greater than or equal to 50% COPD

5

522

Risk Ratio (M‐H, Random, 95% CI)

0.68 [0.46, 1.01]

1.2 Less than 50% COPD

3

83

Risk Ratio (M‐H, Random, 95% CI)

0.51 [0.12, 2.18]

Figures and Tables -
Comparison 14. Noninvasive versus invasive weaning
Comparison 15. Noninvasive versus invasive weaning

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Weaning failure Show forest plot

8

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

2 Nosocomial pneumonia Show forest plot

14

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

3 Average duration of ventilation related to weaning Show forest plot

9

Mean Difference (IV, Random, 95% CI)

Subtotals only

4 Reintubation Show forest plot

10

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

Figures and Tables -
Comparison 15. Noninvasive versus invasive weaning