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 the endotracheal tube and decrease complications associated with prolonged intubation.
Objectives
To summarize the evidence comparing NPPV and invasive positive pressure ventilation (IPPV) weaning on clinical outcomes in intubated adults with respiratory failure.
Search methods
We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 2, 2003), MEDLINE (January 1966 to July 2003) and EMBASE (January 1980 to July 2003) for randomized controlled trials comparing NPPV and IPPV weaning. Additional data sources included personal files, conference proceedings and author contact.
Selection criteria
Randomized and quasi‐randomized studies comparing early extubation with immediate application of NPPV to IPPV weaning in intubated adults with respiratory failure.
Data collection and analysis
Two reviewers independently assessed trial quality and abstracted data according to prespecified criteria. Sensitivity and subgroup analyses were planned to assess the impact of (i) excluding quasi‐randomized trials and (ii) the etiology of respiratory failure on outcomes.
Main results
We identified eleven trials, of which five were included, involving 171 participants with predominantly chronic obstructive pulmonary disease (COPD). Overall, the included studies were of moderate to good quality. Compared to the IPPV strategy, the NPPV strategy decreased mortality (RR 0.41, 95% CI 0.22 to 0.76), the incidence of ventilator associated pneumonia (RR 0.28, 95% CI 0.09 to 0.85), intensive care unit length of stay (WMD ‐6.88 days, 95% CI ‐12.60 to ‐1.15), hospital length of stay (WMD ‐7.33 days, 95%CI ‐14.05 to ‐0.61), total duration of mechanical support (WMD ‐7.33 days, 95% CI ‐11.45 to ‐3.22) and the duration of endotracheal mechanical ventilation (WMD ‐6.32 days, 95% CI ‐12.12 to ‐0.52). There was no effect of NPPV on weaning failures or the duration of mechanical support related to weaning and insufficient data to pool adverse events or quality of life. Excluding a single quasi‐randomized trial maintained the significant reduction in mortality and ventilator associated pneumonia. Subgroup analyses suggested fewer weaning failures and a greater mortality benefit with NPPV in COPD compared to mixed populations, although differences were nonsignificant.
Authors' conclusions
Summary estimates from five studies of moderate to good quality demonstrated a consistent positive effect on overall mortality. Currently, use of NPPV to facilitate weaning in mechanically ventilated patients with predominantly COPD is associated with promising, although insufficient, evidence of net clinical benefit.
PICOs
Plain language summary
Use of noninvasive ventilation (mask with pressurized air) holds promise as a method to help adults with respiratory failure, on ventilators, to breathe for themselves
Results from five randomized controlled trials demonstrate that use of noninvasive ventilation in selected patients with respiratory failure, who can breathe spontaneously and cough, has the potential to decrease mortality, pneumonia, intensive care and hospital length of stay, and the duration of machine support. Insufficient data were available to assess adverse event and failure rates and the impact of this approach on quality of life. Further trials are required to determine the net benefits, risks and consequences associated with this approach.
