Non‐invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary oedema
Information
- DOI:
- https://doi.org/10.1002/14651858.CD005351.pub4Copy DOI
- Database:
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- Cochrane Database of Systematic Reviews
- Version published:
-
- 05 April 2019see what's new
- Type:
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- Intervention
- Stage:
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- Review
- Cochrane Editorial Group:
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Cochrane Heart Group
- Copyright:
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- Copyright © 2019 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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Authors
Contributions of authors
Nicolas Berbenetz proposed the systematic review update, updated the methods, performed study selection, data extraction, 'Risk of bias' assessment, GRADE quality assessment, co‐ordinated the research team, and prepared and updated the review manuscript.
Yongjun Wang assisted with the review update, data extraction, 'Risk of bias' assessment, GRADE quality assessment, and reviewed the final manuscript.
Matthew Chong assisted with the review update, updated the methods, performed study selection, assisted in co‐ordination of the research team, GRADE quality assessment, provided guidance with manuscript preparation, and edited the final manuscript.
Flávia Vital was involved as the lead author of the previous version of this review. She provided her correspondence with authors for unpublished findings.
Charlotte Godfrey assisted with data extraction and reviewed the final manuscript.
Mahmood Ahmad proposed the systematic review update, assisted with data extraction, and reviewed the final manuscript.
James Brown, Pier Lambiase, Amitava Banerjee, and Ameet Bakhai reviewed the final manuscript.
Sources of support
Internal sources
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No sources of support supplied
External sources
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This project was supported by the National Institute for Health Research, via Cochrane Infrastructure funding to the Heart Group. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Systematic Reviews Programme, NIHR, NHS or the Department of Health, UK.
Declarations of interest
Nicolas Berbenetz: none known
Yongjun Wang: none known
James Brown: none known
Charlotte Godfrey: none known
Mahmood Ahmad: none known
Flávia Vital: none known
Pier Lambiase: receives speaker fees and educational grant funding from Boston Scientific, and educational grant funding from Medtronic for work unrelated to the content of this Cochrane review.
Amitava Banerjee: none known
Ameet Bakhai: is employed within the NHS and also advises third sector companies (pharma, device, diagnostics, digital and AI) on trial design, economic models, technology adoption and acts as lecturer for cardiovascular topics. As research director, he also recruits to trials and supports research partnership work for his NHS employer, which attracts commercial research recruitment funding. There are no direct conflicts to the work presented however.
Matthew Chong: none known
Acknowledgements
We thank the Cochrane Heart group for a thoughtful and supportive editorial process. We are grateful to the authors of the studies we reviewed and to those who provided additional data (Räsänen, Bersten, Kelly, Nava, Park, Takeda, Thys, Masip, Bellone, Crane, Ferrari, Agmy, Gray, Weitz, Austin and Belenguer‐Muncharaz). We are also grateful to previous authors of the first and second version of this review: Athallah AN, Burns K, Ladeira MT, Saconato H, Sen A, Hawkes CA, Soares B, and Vital F.
Version history
| Published | Title | Stage | Authors | Version |
| 2019 Apr 05 | Non‐invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary oedema | Review | Nicolas Berbenetz, Yongjun Wang, James Brown, Charlotte Godfrey, Mahmood Ahmad, Flávia MR Vital, Pier Lambiase, Amitava Banerjee, Ameet Bakhai, Matthew Chong | |
| 2013 May 31 | Non‐invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary oedema | Review | Flávia MR Vital, Magdaline T Ladeira, Álvaro N Atallah | |
| 2008 Jul 16 | Non‐invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary edema | Review | Flávia MR Vital, Humberto Saconato, Magdaline T Ladeira , Ayan Sen, Claire A Hawkes, Bernardo Soares, Karen E. A. Burns, Álvaro N Atallah | |
| 2005 Jul 20 | Non‐invasive positive pressure ventilation (CPAP or BiPAP) in cardiogenic pulmonary oedema | Protocol | Flávia MR Vital, Ayan Sen, Álvaro N Atallah, Magdaline Trindade T Ladeira, Bernardo Garcia de Oliveira Soares, Karen E A Burns, C Hawkes | |
Differences between protocol and review
In the previous version of this review (Vital 2013), we stated that acute myocardial infarction (AMI) was an outcome during and after intervention. In this update, we have combined these outcomes, because treatment with SMC or NPPV was not reported in a manner which allowed us to make causal determinations on when AMI occurred relative to the trial intervention (e.g. AMI during or after intervention was not specified). We were unable to include a subgroup analysis comparing AMI at trial inclusion or after NPPV, as the data were not reported consistently. Multiple vital signs were reported as outcomes in the original version of this review. For this update, we have focused on the most clinically relevant outcomes: systolic blood pressure, diastolic blood pressure, and mean blood pressure, which could be a contra‐indication to starting NPPV therapy if too low, and could be expected to decrease with NPPV. Other vital signs such as heart rate are not useful compared to more objective markers of respiratory status such as respiratory rate and PaO2, which we have retained as outcomes. We did not perform a subgroup analysis of adverse events by study publication year before or after 2000. W did perform this analysis in the previous version of this review, but were unable to find a significant change in SMC or NPPV delivery which justified separating studies by any publication year.
Differences between review version from 2013 and this update
There has been a change in the authorship team since the last version of this review in 2013 (Vital 2013). In assuming authorship of this review, we have rerun searches of all databases outlined in the Methods section since 2013. We have also reassessed the inclusion criteria and risks of bias for all trials previously included. For data collection we have included means and standard deviations where available, if an outcome was reported as a median we have approximated it as being equivalent to the mean. We also converted standard error or interquartile ranges to standard deviations using formulae outlined in the Cochrane Handbook (Higgins 2011). In the previous version of this review we included quasi‐randomised controlled trials. We defined quasi‐randomised controlled trials as those where the allocation procedure was unlikely to be adequately randomised (e.g. randomisation according to odd or even numbers, day of the week, social security number, or medical record number). For this update, we have not included these studies, in order to use the highest level of evidence possible to guide the conclusions of our review.
Vital 2013 included studies comparing bilevel NPPV to CPAP without an additional standard medical therapy arm. In this update, we only include studies which compared bilevel NPPV or CPAP or both to standard medical care. These changes led to the inclusion of seven new studies and the exclusion of 15 previously included studies. Please see Included studies and Excluded studies for additional details.
The last authorship team (Vital 2013) performed a grey literature search by contacting authors of included articles for any additional articles on NPPV compared to SMC. We found all previously identified studies using our updated search strategy. In addition, we were able to identify seven new studies. We therefore did not repeat the grey literature search outside of the explicit databases named in our search strategy.
Keywords
MeSH
Medical Subject Headings (MeSH) Keywords
Medical Subject Headings Check Words
Adult; Humans;
PICOs
PRISMA statement flow diagram for 2019 review update.
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Funnel plot of comparison: 1 NPPV vs SMC, outcome: 1.1 HOSPITAL MORTALITY.
Funnel plot of comparison: 1 NPPV vs SMC, outcome: 1.8 ETI RATE.
Funnel plot of comparison: 1 NPPV vs SMC, outcome: 1.17 HOSPITAL LENGTH OF STAY.
Comparison 1 NPPV vs SMC, Outcome 1 HOSPITAL MORTALITY.
Comparison 1 NPPV vs SMC, Outcome 2 Hospital mortality ‐ by NPPV.
Comparison 1 NPPV vs SMC, Outcome 3 Hospital mortality ‐ by location.
Comparison 1 NPPV vs SMC, Outcome 4 Hospital mortality ‐ by baseline PaCO2.
Comparison 1 NPPV vs SMC, Outcome 5 Hospital mortality ‐ sensitivity analysis (low risk of bias).
Comparison 1 NPPV vs SMC, Outcome 6 Hospital mortality ‐ sensitivity analysis (missing data).
Comparison 1 NPPV vs SMC, Outcome 7 Hospital mortality ‐ sensitivity analysis (fixed‐effect).
Comparison 1 NPPV vs SMC, Outcome 8 ETI RATE.
Comparison 1 NPPV vs SMC, Outcome 9 ETI rate ‐ by NPPV.
Comparison 1 NPPV vs SMC, Outcome 10 ETI rate ‐ by location.
Comparison 1 NPPV vs SMC, Outcome 11 ETI rate ‐ by baseline PaCO2.
Comparison 1 NPPV vs SMC, Outcome 12 ETI rate ‐ sensitivity analysis (low risk of bias).
Comparison 1 NPPV vs SMC, Outcome 13 ETI rate ‐ sensitivity analysis (missing data).
Comparison 1 NPPV vs SMC, Outcome 14 ETI rate ‐ by face mask type.
Comparison 1 NPPV vs SMC, Outcome 15 ACUTE MI INCIDENCE.
Comparison 1 NPPV vs SMC, Outcome 16 Acute MI incidence ‐ by NPPV.
Comparison 1 NPPV vs SMC, Outcome 17 HOSPITAL LENGTH OF STAY.
Comparison 1 NPPV vs SMC, Outcome 18 Hospital length of stay ‐ by NPPV.
Comparison 1 NPPV vs SMC, Outcome 19 Hospital length of stay ‐ by location.
Comparison 1 NPPV vs SMC, Outcome 20 Hospital length of stay ‐ by baseline PaCO2.
Comparison 1 NPPV vs SMC, Outcome 21 ICU LENGTH OF STAY.
Comparison 1 NPPV vs SMC, Outcome 22 SYSTOLIC BP AFTER ONE HOUR.
Comparison 1 NPPV vs SMC, Outcome 23 Systolic BP after one hour ‐ by NPPV.
Comparison 1 NPPV vs SMC, Outcome 24 DIASTOLIC BP AFTER ONE HOUR.
Comparison 1 NPPV vs SMC, Outcome 25 Diastolic BP after one hour ‐ by NPPV.
Comparison 1 NPPV vs SMC, Outcome 26 MEAN BP AFTER ONE HOUR.
Comparison 1 NPPV vs SMC, Outcome 27 RESPIRATORY RATE AFTER ONE HOUR.
Comparison 1 NPPV vs SMC, Outcome 28 Respiratory rate after one hour ‐ by NPPV.
Comparison 1 NPPV vs SMC, Outcome 29 PaO2 (mmHg) AFTER ONE HOUR.
Comparison 1 NPPV vs SMC, Outcome 30 PaO2 (mmHg) after one hour ‐ by NPPV.
Comparison 1 NPPV vs SMC, Outcome 31 ADVERSE EVENTS.
| NPPV compared to standard medical care for cardiogenic pulmonary oedema | ||||||
| Patient or population: People with cardiogenic pulmonary oedema | ||||||
| Outcomes | Anticipated absolute effects* (95% CI) | Relative effect | № of participants | Certainty of the evidence | Comments | |
| Risk with SMC | Risk with NPPV | |||||
| HOSPITAL MORTALITY | Study population | RR 0.65 | 2484 | ⊕⊕⊝⊝ | ‐ | |
| 176 per 1000 | 114 per 1000 | |||||
| ETI RATE range 0.1 day ‐ 30 days | Study population | RR 0.49 | 2449 | ⊕⊕⊕⊝ | ‐ | |
| 154 per 1000 | 75 per 1000 | |||||
| ACUTE MI INCIDENCE | Study population | RR 1.03 | 1313 | ⊕⊕⊕⊝ | ‐ | |
| 421 per 1000 | 433 per 1000 | |||||
| HOSPITAL LENGTH OF STAY | The mean HOSPITAL LENGTH OF STAY was 9.65 days | MD 0.31 days lower | ‐ | 1714 | ⊕⊝⊝⊝ | ‐ |
| ICU LENGTH OF STAY | This outcome could not be pooled due to high heterogeneity. There was no evidence of a difference between NPPV and SMC in 4 RCTs, and 2 RCTs reported a shorter length of stay for NPPV (1 day shorter (95% CI −1.79 to −0.21); n = 30; 4 days shorter (95% CI −4.36 to −3.64); n = 120) | ‐ | 587 | ⊕⊝⊝⊝ | Data were not pooled due to high heterogeneity with an I2 of 99% | |
| INTOLERANCE TO ALLOCATED TREATMENT ‐ not reported | ‐ | ‐ | ‐ | ‐ | ‐ | Outcome was not reported |
| ADVERSE EVENTS | Reported adverse events included skin damage, pneumonia, gastrointestinal bleeding, gastric distention, vomiting, pneumothorax, sinusitis, mask discomfort, hypotension, arrhythmia, cardiorespiratory arrest, gastric aspiration, stroke, seizures, claustrophobia, and hypercapnia. There was no evidence of a difference between groups for most of these events. However, there was an increase in discomfort with mask reported with NPPV (35/658) compared with SMC (0/442); RR 12.59 (95% CI 2.39 to 66.28). One small study (n = 83) reported a higher incidence of gastric distention in the NPPV group (13/56 in NPPV group, 0/27 in SMC group; RR 13.26 (95% CI 0.82 to 215.12)), but the number of events was low and the confidence interval wide. There was also some weak evidence of a lower incidence of cardiorespiratory arrest in the NPPV group (24/836 (NPPV) vs 26/516 (SMC); RR 0.60 (95% CI 0.34 to 1.05) | ‐ | 2038 | ⊕⊕⊝⊝ | ‐ | |
| *The risk in the intervention group (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). | ||||||
| GRADE Working Group grades of evidence | ||||||
| aDowngraded by one level for risk of bias. Most trials providing hospital mortality evidence were at unclear or high risk of bias for key domains, including: randomisation sequence, allocation concealment, selective reporting bias, and other significant bias. | ||||||
| Study | Mask type | IPAP level (cmH2O) ± SD | EPAP in bilevel NPPV (cmH2O) ± SD | PEEP in CPAP (cmH2O) ± SD | Time of bilevel NPPV (h) ± SD | Time of CPAP (h) ± SD |
| Face mask | NA | NA | NA | NA | NA | |
| Face mask | NA | NA | 10 | NA | 0.583333 | |
| Face mask | 15 | 5 | 10 | NA | NA | |
| Face mask | NA | NA | 10 | NA | 3 | |
| Face mask | 15 | 10 | 10 | 1 | ‐ | |
| Face mask | NA | NA | 10 | NA | NA | |
| Face mask | 14±5 | 7 ± 3 | 10 ± 4 | 2 ± 1.3 | 2.2 ± 1.5 | |
| Face mask | NA | NA | 6 to 10 | NA | 4.6 ± 2.8 | |
| Face mask | NA | NA | 7.5 | NA | NA | |
| Face mask | NA | NA | 7.5 | NA | NA | |
| Face mask selected for mouth breathers Nasal available | NA | NA | NA | 2 | 2 | |
| Face mask | 15 to 18 | 5 to 8 | NA | 2 | NA | |
| Face mask | NA | NA | 12.5 | NA | 6 | |
| Face mask | NA | NA | 12.5 | NA | 6 | |
| Face mask | 15.2 ± 2.4 | 5 | NA | 4.2 ± 1.5 | NA | |
| Face mask | NA | NA | 9.3 ± 0.3 | 0.5 | NA | |
| Face mask | 14.5 ± 21.1 | 6.1 ± 3.2 | NA | 11.4 ± 3.6 | NA | |
| Nasal bilevel and face mask for CPAP | 12 | 4 | 7.5 | 2.6 ± 0.6 | 2.8 ± 1.5 | |
| Face mask | 17 ± 2 | 11 ± 2 | 11 ± 2 | 2.1 ± 1 | 1.7 ± 0.7 | |
| Face mask | NA | NA | 10 | NA | NA | |
| Nasal | NA | NA | 4 to 10 | 11.9 ± 8.4 | NA | |
| Nasal | NA | NA | 4 to 10 | NA | NA | |
| Face mask | 16.5 ± 3.3 | 6.1 ± 1.5 | NA | 1.3 ± 0.3 | NA | |
| Face mask 1st, nasal 2nd | 10 to 20 | 4 to 7 | NA | 1 | NA | |
| Not all papers provided a mean and standard deviation. Where unavailable, the range represents the IPAP/EPAP/CPAP settings described in the Methods. NA: not applicable | ||||||
| Study | Lasix | Lasix dose | Nitrate | FiO2 mask and %FiO2 | Other | Additional differences between SMC received in treatment group |
| Unclear | Unclear | Unclear | Unclear | Unclear | Unclear | |
| yes | 40 mg | Sublingual 400 ‐ 1600 mcg q5min | Yes, 8 ‐ 15 Lpm | Morphine 1 ‐ 2 mg IV | None | |
| yes | Unclear | nitrates | Yes, 10 Lpm | diamorphine | None | |
| yes | Lasix 40 mg ‐ 120 mg IV or 1 ‐ 3 mg bumetanide | nitroglycerin (1 mg per 3 min) and a continuous IV infusion unless systolic BP < 110 mmHg | 15 Lpm | NA | None | |
| yes | Lasix 40 mg IV | nitroglycerin 0.4 mg sublingual | 15 Lpm | Morphine 2 mg IV | None | |
| yes | 1 mg/kg IV | isosorbide dinitrate IV 2 mg if SBP > 180 mmHg | 15 Lpm | NA | None | |
| yes | 50 mg above usual dose to max 100 mg IV | Buccal nitrates 2 ‐ 5 mg | 15 Lpm | Opiates | None | |
| yes | 20 ‐ 40 mg IV | Buccal nitrates 0.5 mg to 1 mg IV | 6 Lpm | Morphine 2 mg IV | None | |
| yes | 50 ‐ 100 mg IV | buccal nitrate 5 mg if systolic BP > 90 mmHg | oxygen 60% by venturi mask | morphine IV 2.5 ‐ 10 mg | None | |
| yes | Unclear | nitroglycerin | Mask high concentration | Unclear | None | |
| yes | Unclear | nitroglycerin IV | Mask high flow | Morphine | None | |
| yes | 80 mg IV | nitroglycerin IV infusion 1 mg/hour | 8 Lpm | Morphine 2 ‐ 10 mg IV | None | |
| Unclear | Unclear | Unclear | FiO2 100% | Unclear | Unclear | |
| yes | 40 mg IV or double home dose | nitroglycerin sublingual 0.6 mg or isosorbide 10 ‐ 20 mg, or nitro infusion 10 ‐ 50 mcg/min | FiO2 100% | Morphine 2 ‐ 10 mg IV | None | |
| yes | 40 mg IV | IV glyceryl trinitrate 1mg if systolic BP > 180 mmHg | FiO2 50% | Morphine 4 mg IV | None | |
| yes | 40 mg IV or double home dose | IV nitroglycerin infusion 0.125 ‐ 0.25 mcg/kg/min | FiO2 100% | Unclear | None | |
| yes | 40 mg IV or double usual dose, repeated, if necessary, every 20 mins, up to 320 mg | continuous glyceryl trinitrate at an initial rate of 1.5 mg/hour. A bolus dose of 1 mg IV was added if systolic BP > 180 mmHg | 10 Lpm | morphine sulphate up to 4 mg | None | |
| Unclear | Unclear | 5 mg isosorbide dinitrite if systolic BP > 100 mm Hg | 15 Lpm | Unclear | Unclear | |
| Unclear | Unclear | 5 mg isosorbide dinitrate was given sublingually and if necessary titrated up to 15 mg | FiO2 50% | Unclear | Unclear | |
| yes | 40 ‐ 80 mg IV | Nitroprusside, nitroglycerine | FiO2 30% | Morphine | Unclear | |
| yes | Unclear | Nitroglycerin infusion | FiO2 50% | Morphine | Unclear | |
| yes | Unclear | Nitroglycerin infusion | FiO2 70% | Morphine | Unclear | |
| yes | 40 mg IV | isosorbide dinitrate 2 mg/hour | Unclear | Unclear | Unclear | |
| yes | 40 ‐ 320 mg | IV nitroglycerin 5 ‐ 50 mcg/kg/min | 10 Lpm | morphine 5 ‐ 10 mg | Unclear | |
| BP: blood pressure; FiO2: fraction of inspired oxygen; IV: intravenous; Lpm: litres per minute; NA: not available; mcg: micrograms; mcg/kg/min: micrograms per kilogram per minute; mg: milligrams; min: minutes; mmHg = millimetres of mercury | ||||||
| Study | Follow‐up (days) |
| Unclear | |
| 7.2a | |
| 41b | |
| > 7 | |
| 1 | |
| 30 | |
| 30 | |
| NA | |
| 15a | |
| NA | |
| 38b | |
| 12a | |
| 1 | |
| 9 | |
| 14a | |
| NA | |
| 5.4a | |
| 3b | |
| 15 | |
| Unclear | |
| 7.7a | |
| Unclear | |
| 17.6a | |
| 7 | |
| aEstimated based on longest reported mean hospital length of stay; bBased on latest death reported in trial | |
| Study | Intubation Criteria |
| Unclear | |
| Unclear | |
| RR > 40, RR < 10, altered level of consciousness, arterial pH < 7.2 | |
| SpO2 < 85% after 30 mins of 15 Lpm or FiO2 60% CPAP, respiratory arrest, psychomotor agitation, SBP < 80 mmHg | |
| Unclear | |
| Worsening SpO2 despite effective treatment, loss of airway protective reflexes (cough, swallow), decreased level of consciousness, haemodynamic instability, intolerance/poor fit of face mask for the CPAP group, medical clinical impression of deterioration, or participant request | |
| At discretion of treating clinician | |
| Cardiac or respiratory arrest, severe haemodynamic instability (SBP < 80), administration of epinephrine/norepinephrine, refractory hypoxaemia SaO2 < 92% despite face mask, clinical signs of respiratory exhaustion (accessory muscle use with paradoxical abdominal motion), coma or seizures, agitation requiring sedation | |
| Clinical or arterial blood gas findings. Severe respiratory distress, deterioration in mental status, or further deterioration in vital signs with increasing HR, RR, or a decrease in BP. Decrease in pO2 < 60 or rise in pCO2 > 50 along with signs of clinical deterioration warranted intubation | |
| Clinician discretion. Loss of consciousness or airway obstruction were indications for intubation | |
| Cardiopulmonary resuscitation or clinical deterioration with any 2 of the following: (1) a rise in arterial carbon dioxide tension to more than 55 mm Hg; (2) arterial blood oxygen partial pressure divided by fraction of inspired oxygen content less than 200 mm Hg; and (3) respiratory rate over 35 breaths/min. | |
| Patients were intubated when the criteria for treatment failure were met. Details not specified. | |
| Unclear | |
| Clinical judgement | |
| Clinical judgement | |
| Clinical judgement. Loss of consciousness or airway obstruction were indications for intubation at any time. | |
| Clinical deterioration and either a decrease in the PaO2/FiO2 < 100 with an FIO2 ≥ 70% or a increase in the PaCO2 > 55 mmHg | |
| Clinical deterioration and either a fall in PaO2/FiO2 < 100 with an FiO2 of 70% or a rise in PaCO2 to > 55 mmHg. | |
| Deterioration in clinical status including all of the following: dyspnoea, respiratory or heart frequency or both, sweating and agitation or deterioration in blood gases or in haemodynamic status or both | |
| RR after 1 hour of bilevel NPPV > 30, persistent hypoxaemia, haemodynamic instability (systolic BP < 70), agitation, or worsened neurologic status, inability to tolerate mask or aspiration of gastric content | |
| BP: blood pressure; CPAP: continuous positive airway pressure; FiO2: fraction of inspired oxygen; HR: heart rate; Lpm: litres per minute; PaCO2: arterial partial pressure of carbon dioxide; PaO2: arterial partial pressure of oxygen; RR: respiratory rate; SBP: systolic blood pressure | |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 HOSPITAL MORTALITY Show forest plot | 21 | 2484 | Risk Ratio (M‐H, Random, 95% CI) | 0.65 [0.51, 0.82] |
| 2 Hospital mortality ‐ by NPPV Show forest plot | 21 | 2484 | Risk Ratio (M‐H, Random, 95% CI) | 0.71 [0.58, 0.87] |
| 2.1 CPAP vs SMC | 16 | 1454 | Risk Ratio (M‐H, Random, 95% CI) | 0.65 [0.48, 0.88] |
| 2.2 bilevel NPPV vs SMC | 11 | 1030 | Risk Ratio (M‐H, Random, 95% CI) | 0.72 [0.53, 0.98] |
| 3 Hospital mortality ‐ by location Show forest plot | 21 | 2484 | Risk Ratio (M‐H, Random, 95% CI) | 0.65 [0.51, 0.82] |
| 3.1 ER | 10 | 1596 | Risk Ratio (M‐H, Random, 95% CI) | 0.66 [0.47, 0.93] |
| 3.2 ICU | 10 | 862 | Risk Ratio (M‐H, Random, 95% CI) | 0.52 [0.35, 0.77] |
| 3.3 unclear | 1 | 26 | Risk Ratio (M‐H, Random, 95% CI) | 1.94 [0.09, 43.50] |
| 4 Hospital mortality ‐ by baseline PaCO2 Show forest plot | 21 | 2484 | Risk Ratio (M‐H, Random, 95% CI) | 0.65 [0.51, 0.82] |
| 4.1 PaCO2 <= 45mmHg | 10 | 581 | Risk Ratio (M‐H, Random, 95% CI) | 0.41 [0.27, 0.63] |
| 4.2 PaCO2 > 45mmHg | 11 | 1903 | Risk Ratio (M‐H, Random, 95% CI) | 0.82 [0.65, 1.03] |
| 5 Hospital mortality ‐ sensitivity analysis (low risk of bias) Show forest plot | 7 | 1505 | Risk Ratio (M‐H, Random, 95% CI) | 0.81 [0.61, 1.06] |
| 6 Hospital mortality ‐ sensitivity analysis (missing data) Show forest plot | 18 | 2283 | Risk Ratio (M‐H, Random, 95% CI) | 0.68 [0.54, 0.86] |
| 7 Hospital mortality ‐ sensitivity analysis (fixed‐effect) Show forest plot | 21 | 2484 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.67 [0.55, 0.81] |
| 8 ETI RATE Show forest plot | 20 | 2449 | Risk Ratio (M‐H, Random, 95% CI) | 0.49 [0.38, 0.62] |
| 9 ETI rate ‐ by NPPV Show forest plot | 20 | 2449 | Risk Ratio (M‐H, Random, 95% CI) | 0.49 [0.39, 0.63] |
| 9.1 CPAP vs SMC | 15 | 1413 | Risk Ratio (M‐H, Random, 95% CI) | 0.46 [0.34, 0.62] |
| 9.2 Bilevel NPPV vs SMC | 11 | 1036 | Risk Ratio (M‐H, Random, 95% CI) | 0.50 [0.31, 0.81] |
| 10 ETI rate ‐ by location Show forest plot | 20 | 2449 | Risk Ratio (M‐H, Random, 95% CI) | 0.49 [0.38, 0.62] |
| 10.1 ER | 9 | 1561 | Risk Ratio (M‐H, Random, 95% CI) | 0.60 [0.37, 0.96] |
| 10.2 ICU | 10 | 862 | Risk Ratio (M‐H, Random, 95% CI) | 0.40 [0.29, 0.56] |
| 10.3 unclear | 1 | 26 | Risk Ratio (M‐H, Random, 95% CI) | 0.47 [0.13, 1.67] |
| 11 ETI rate ‐ by baseline PaCO2 Show forest plot | 20 | 2449 | Risk Ratio (M‐H, Random, 95% CI) | 0.49 [0.38, 0.62] |
| 11.1 PaCO2 <= 45mmHg | 9 | 523 | Risk Ratio (M‐H, Random, 95% CI) | 0.37 [0.26, 0.52] |
| 11.2 PaCO2 > 45mmHg | 11 | 1926 | Risk Ratio (M‐H, Random, 95% CI) | 0.64 [0.46, 0.91] |
| 12 ETI rate ‐ sensitivity analysis (low risk of bias) Show forest plot | 6 | 1491 | Risk Ratio (M‐H, Random, 95% CI) | 0.85 [0.55, 1.32] |
| 13 ETI rate ‐ sensitivity analysis (missing data) Show forest plot | 17 | 2248 | Risk Ratio (M‐H, Random, 95% CI) | 0.52 [0.40, 0.69] |
| 14 ETI rate ‐ by face mask type Show forest plot | 20 | 2449 | Risk Ratio (M‐H, Random, 95% CI) | 0.49 [0.38, 0.62] |
| 14.1 Exclusive full face mask use | 15 | 2213 | Risk Ratio (M‐H, Random, 95% CI) | 0.52 [0.40, 0.69] |
| 14.2 Exclusive or permissive nasal mask use | 5 | 236 | Risk Ratio (M‐H, Random, 95% CI) | 0.35 [0.20, 0.62] |
| 15 ACUTE MI INCIDENCE Show forest plot | 5 | 1313 | Risk Ratio (M‐H, Random, 95% CI) | 1.03 [0.91, 1.16] |
| 16 Acute MI incidence ‐ by NPPV Show forest plot | 5 | 1313 | Risk Ratio (M‐H, Random, 95% CI) | 1.03 [0.91, 1.16] |
| 16.1 CPAP vs SMC | 3 | 569 | Risk Ratio (M‐H, Random, 95% CI) | 0.96 [0.80, 1.14] |
| 16.2 bilevel NPPV vs SMC | 5 | 744 | Risk Ratio (M‐H, Random, 95% CI) | 1.09 [0.92, 1.29] |
| 17 HOSPITAL LENGTH OF STAY Show forest plot | 11 | 1714 | Mean Difference (IV, Random, 95% CI) | ‐0.31 [‐1.23, 0.61] |
| 18 Hospital length of stay ‐ by NPPV Show forest plot | 11 | 1714 | Mean Difference (IV, Random, 95% CI) | ‐0.19 [‐1.02, 0.64] |
| 18.1 CPAP vs SMC | 7 | 943 | Mean Difference (IV, Random, 95% CI) | ‐0.52 [‐1.77, 0.72] |
| 18.2 bilevel NPPV vs SMC | 6 | 771 | Mean Difference (IV, Random, 95% CI) | 0.39 [‐0.35, 1.13] |
| 19 Hospital length of stay ‐ by location Show forest plot | 11 | 1714 | Mean Difference (IV, Random, 95% CI) | ‐0.30 [‐1.21, 0.61] |
| 19.1 ER | 8 | 1455 | Mean Difference (IV, Random, 95% CI) | ‐0.38 [‐1.70, 0.93] |
| 19.2 ICU | 3 | 259 | Mean Difference (IV, Random, 95% CI) | ‐0.21 [‐1.30, 0.89] |
| 20 Hospital length of stay ‐ by baseline PaCO2 Show forest plot | 11 | 1714 | Mean Difference (IV, Random, 95% CI) | ‐0.30 [‐1.21, 0.61] |
| 20.1 PaCO2 <= 45mmHg | 5 | 397 | Mean Difference (IV, Random, 95% CI) | ‐1.18 [‐2.33, ‐0.04] |
| 20.2 PaCO2 > 45mmHg | 6 | 1317 | Mean Difference (IV, Random, 95% CI) | 0.60 [‐0.15, 1.34] |
| 21 ICU LENGTH OF STAY Show forest plot | 6 | Mean Difference (IV, Random, 95% CI) | Totals not selected | |
| 22 SYSTOLIC BP AFTER ONE HOUR Show forest plot | 7 | 1408 | Mean Difference (IV, Random, 95% CI) | ‐1.72 [‐5.03, 1.58] |
| 23 Systolic BP after one hour ‐ by NPPV Show forest plot | 7 | 1408 | Mean Difference (IV, Random, 95% CI) | ‐1.72 [‐5.03, 1.59] |
| 23.1 CPAP vs SMC | 7 | 866 | Mean Difference (IV, Random, 95% CI) | ‐1.65 [‐5.58, 2.28] |
| 23.2 bilevel NPPV vs SMC | 3 | 542 | Mean Difference (IV, Random, 95% CI) | ‐1.89 [‐8.01, 4.23] |
| 24 DIASTOLIC BP AFTER ONE HOUR Show forest plot | 6 | 1361 | Mean Difference (IV, Random, 95% CI) | 1.46 [‐1.86, 4.78] |
| 25 Diastolic BP after one hour ‐ by NPPV Show forest plot | 6 | 1361 | Mean Difference (IV, Random, 95% CI) | 1.05 [‐2.15, 4.25] |
| 25.1 CPAP vs SMC | 6 | 823 | Mean Difference (IV, Random, 95% CI) | 0.92 [‐3.92, 5.75] |
| 25.2 bilevel NPPV vs SMC | 3 | 538 | Mean Difference (IV, Random, 95% CI) | 1.08 [‐2.88, 5.04] |
| 26 MEAN BP AFTER ONE HOUR Show forest plot | 3 | 251 | Mean Difference (IV, Random, 95% CI) | ‐2.50 [‐8.29, 3.30] |
| 27 RESPIRATORY RATE AFTER ONE HOUR Show forest plot | 10 | 1636 | Mean Difference (IV, Random, 95% CI) | ‐1.87 [‐2.70, ‐1.03] |
| 28 Respiratory rate after one hour ‐ by NPPV Show forest plot | 10 | 1636 | Mean Difference (IV, Random, 95% CI) | ‐1.58 [‐2.22, ‐0.94] |
| 28.1 CPAP vs SMC | 10 | 1107 | Mean Difference (IV, Random, 95% CI) | ‐1.64 [‐2.41, ‐0.87] |
| 28.2 bilevel NPPV vs SMC | 3 | 529 | Mean Difference (IV, Random, 95% CI) | ‐2.17 [‐4.69, 0.35] |
| 29 PaO2 (mmHg) AFTER ONE HOUR Show forest plot | 10 | 1428 | Mean Difference (IV, Random, 95% CI) | 16.19 [3.54, 28.84] |
| 30 PaO2 (mmHg) after one hour ‐ by NPPV Show forest plot | 10 | 1428 | Mean Difference (IV, Random, 95% CI) | 13.74 [2.72, 24.76] |
| 30.1 CPAP vs SMC | 8 | 761 | Mean Difference (IV, Random, 95% CI) | 9.55 [‐9.10, 28.19] |
| 30.2 bilevel NPPV vs SMC | 6 | 667 | Mean Difference (IV, Random, 95% CI) | 19.50 [4.29, 34.71] |
| 31 ADVERSE EVENTS Show forest plot | 11 | 9570 | Risk Ratio (M‐H, Random, 95% CI) | 1.04 [0.73, 1.50] |
| 31.1 Skin damage | 2 | 190 | Risk Ratio (M‐H, Random, 95% CI) | 9.09 [0.74, 111.09] |
| 31.2 Pneumonia | 1 | 130 | Risk Ratio (M‐H, Random, 95% CI) | 0.5 [0.05, 5.38] |
| 31.3 Gastrointestinal bleeding | 2 | 170 | Risk Ratio (M‐H, Random, 95% CI) | 2.32 [0.35, 15.42] |
| 31.4 Gastric distention | 1 | 83 | Risk Ratio (M‐H, Random, 95% CI) | 13.26 [0.82, 215.12] |
| 31.5 Vomiting | 5 | 1467 | Risk Ratio (M‐H, Random, 95% CI) | 1.03 [0.49, 2.17] |
| 31.6 Pneumothorax | 2 | 1165 | Risk Ratio (M‐H, Random, 95% CI) | 0.72 [0.08, 6.89] |
| 31.7 Sinusitis | 1 | 130 | Risk Ratio (M‐H, Random, 95% CI) | 3.0 [0.12, 72.31] |
| 31.8 Discomfort with mask | 3 | 1100 | Risk Ratio (M‐H, Random, 95% CI) | 12.59 [2.39, 66.28] |
| 31.9 Hypotension | 1 | 1030 | Risk Ratio (M‐H, Random, 95% CI) | 0.82 [0.58, 1.16] |
| 31.10 Arrhythmia | 1 | 1027 | Risk Ratio (M‐H, Random, 95% CI) | 0.83 [0.50, 1.38] |
| 31.11 Cardiorespiratory arrest | 4 | 1352 | Risk Ratio (M‐H, Random, 95% CI) | 0.60 [0.34, 1.05] |
| 31.12 Gastric aspiration | 1 | 1037 | Risk Ratio (M‐H, Random, 95% CI) | 1.58 [0.06, 38.61] |
| 31.13 Stroke | 1 | 130 | Risk Ratio (M‐H, Random, 95% CI) | 0.2 [0.01, 4.09] |
| 31.14 Seizures | 1 | 130 | Risk Ratio (M‐H, Random, 95% CI) | 0.33 [0.01, 8.03] |
| 31.15 Claustrophobia | 1 | 130 | Risk Ratio (M‐H, Random, 95% CI) | 3.0 [0.12, 72.31] |
| 31.16 Hypercapnia | 3 | 299 | Risk Ratio (M‐H, Random, 95% CI) | 0.76 [0.16, 3.62] |
