Noninvasive positive‐pressure ventilation as a weaning strategy for intubated adults with respiratory failure
Abstract
Background
Noninvasive positive‐pressure ventilation (NPPV) provides ventilatory support without the need for an invasive airway. Interest has emerged in using NPPV to facilitate earlier removal of an endotracheal tube and to decrease complications associated with prolonged intubation.
Objectives
We evaluated studies in which invasively ventilated adults with respiratory failure of any cause (chronic obstructive pulmonary disease (COPD), non‐COPD, postoperative, nonoperative) were weaned by means of early extubation followed by immediate application of NPPV or continued IPPV weaning. The primary objective was to determine whether the noninvasive positive‐pressure ventilation (NPPV) strategy reduced all‐cause mortality compared with invasive positive‐pressure ventilation (IPPV) weaning. Secondary objectives were to ascertain differences between strategies in proportions of weaning failure and ventilator‐associated pneumonia (VAP), intensive care unit (ICU) and hospital length of stay (LOS), total duration of mechanical ventilation, duration of mechanical support related to weaning, duration of endotracheal mechanical ventilation (ETMV), frequency of adverse events (related to weaning) and overall quality of life. We planned sensitivity and subgroup analyses to assess (1) the influence on mortality and VAP of excluding quasi‐randomized trials, and (2) effects on mortality and weaning failure associated with different causes of respiratory failure (COPD vs. mixed populations).
Search methods
We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 5, 2013), MEDLINE (January 1966 to May 2013), EMBASE (January 1980 to May 2013), proceedings from four conferences, trial registration websites and personal files; we contacted authors to identify trials comparing NPPV versus conventional IPPV weaning.
Selection criteria
Randomized and quasi‐randomized trials comparing early extubation with immediate application of NPPV versus IPPV weaning in intubated adults with respiratory failure.
Data collection and analysis
Two review authors independently assessed trial quality and abstracted data according to prespecified criteria. Sensitivity and subgroup analyses assessed (1) the impact of excluding quasi‐randomized trials, and (2) the effects on selected outcomes noted with different causes of respiratory failure.
Main results
We identified 16 trials, predominantly of moderate to good quality, involving 994 participants, most with chronic obstructive pulmonary disease (COPD). Compared with IPPV weaning, NPPV weaning significantly decreased mortality. The benefits for mortality were significantly greater in trials enrolling exclusively participants with COPD (risk ratio (RR) 0.36, 95% confidence interval (CI) 0.24 to 0.56) versus mixed populations (RR 0.81, 95% CI 0.47 to 1.40). NPPV significantly reduced weaning failure (RR 0.63, 95% CI 0.42 to 0.96) and ventilator‐associated pneumonia (RR 0.25, 95% CI 0.15 to 0.43); shortened length of stay in an intensive care unit (mean difference (MD) ‐5.59 days, 95% CI ‐7.90 to ‐3.28) and in hospital (MD ‐6.04 days, 95% CI ‐9.22 to ‐2.87); and decreased the total duration of ventilation (MD ‐5.64 days, 95% CI ‐9.50 to ‐1.77) and the duration of endotracheal mechanical ventilation (MD ‐ 7.44 days, 95% CI ‐10.34 to ‐4.55) amidst significant heterogeneity. Noninvasive weaning also significantly reduced tracheostomy (RR 0.19, 95% CI 0.08 to 0.47) and reintubation (RR 0.65, 95% CI 0.44 to 0.97) rates. Noninvasive weaning had no effect on the duration of ventilation related to weaning. Exclusion of a single quasi‐randomized trial did not alter these results. Subgroup analyses suggest that the benefits for mortality were significantly greater in trials enrolling exclusively participants with COPD versus mixed populations.
Authors' conclusions
Summary estimates from 16 trials of moderate to good quality that included predominantly participants with COPD suggest that a weaning strategy that includes NPPV may reduce rates of mortality and ventilator‐associated pneumonia without increasing the risk of weaning failure or reintubation.
PICOs
Plain language summary
Use of noninvasive ventilation (a mask ventilator) holds promise as a method to make it easier to remove adults from conventional ventilators.
Patients with acute respiratory failure frequently require endotracheal intubation and mechanical ventilation (invasive positive‐pressure ventilation) to sustain life. Complications of mechanical ventilation include respiratory muscle weakness, upper airway injury, ventilator‐associated pneumonia, sinusitis and associated death. For these reasons, it is important to minimize the duration of mechanical ventilation. Noninvasive positive‐pressure ventilation is achieved with an oronasal, nasal or total face mask connected to a positive‐pressure ventilator and does not require an indwelling artificial airway.
Results from 16 randomized controlled trials, predominantly of moderate to good quality, involving 994 selected participants, approximately two thirds with chronic obstructive pulmonary disease who had respiratory failure and were starting to breathe spontaneously, demonstrate that support with noninvasive ventilation can decrease death, weaning failure, pneumonia and length of stay in the intensive care unit and hospital. Noninvasive weaning also decreased the total duration of ventilation and the time spent on invasive ventilation, as well as the number of participants who received a tracheostomy. Although noninvasive weaning had no effect on the duration of mechanical ventilation related to weaning, it did not increase the reintubation rate. Insufficient data were available to assess its impact on quality of life. Noninvasive weaning significantly reduced mortality in chronic obstructive pulmonary disease studies versus mixed population studies.
