Non‐invasive positive pressure ventilation for treatment of respiratory failure due to exacerbations of chronic obstructive pulmonary disease

Felix S F Ram; Joanna Picot; J Lightowler; J A Wedzicha

doi:10.1002/14651858.CD004104.pub2

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Analysis 1.1

Comparison 1 NPPV +Usual Medical Care vs Usual Medical Care ‐ Overall, Outcome 1 Treatment failure.

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Analysis 1.2

Comparison 1 NPPV +Usual Medical Care vs Usual Medical Care ‐ Overall, Outcome 2 Mortality.

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Analysis 1.3

Comparison 1 NPPV +Usual Medical Care vs Usual Medical Care ‐ Overall, Outcome 3 Intubation.

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Analysis 1.4

Comparison 1 NPPV +Usual Medical Care vs Usual Medical Care ‐ Overall, Outcome 4 Length of hospital stay (days).

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Analysis 1.5

Comparison 1 NPPV +Usual Medical Care vs Usual Medical Care ‐ Overall, Outcome 5 Length of ICU stay (days).

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Analysis 1.6

Comparison 1 NPPV +Usual Medical Care vs Usual Medical Care ‐ Overall, Outcome 6 Complications of treatment.

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Analysis 1.7

Comparison 1 NPPV +Usual Medical Care vs Usual Medical Care ‐ Overall, Outcome 7 Symptom scores (higher score means more dyspnoea).

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Analysis 1.8

Comparison 1 NPPV +Usual Medical Care vs Usual Medical Care ‐ Overall, Outcome 8 pH 1 hour post intervention.

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Analysis 1.9

Comparison 1 NPPV +Usual Medical Care vs Usual Medical Care ‐ Overall, Outcome 9 pH 1 hour post intervention (without Avdeev and Conti studies).

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Analysis 1.10

Comparison 1 NPPV +Usual Medical Care vs Usual Medical Care ‐ Overall, Outcome 10 PaCO2 kPa ‐ 1 hour post intervention.

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Analysis 1.11

Comparison 1 NPPV +Usual Medical Care vs Usual Medical Care ‐ Overall, Outcome 11 PaCO2 kPa ‐ 1 hour post intervention (without Avdeev and Conti studies).

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Analysis 1.12

Comparison 1 NPPV +Usual Medical Care vs Usual Medical Care ‐ Overall, Outcome 12 PaO2 kPa ‐ 1 hour post intervention.

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Analysis 1.13

Comparison 1 NPPV +Usual Medical Care vs Usual Medical Care ‐ Overall, Outcome 13 PaO2 kPa ‐ 1 hour post intervention (without Avdeev study).

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Analysis 1.14

Comparison 1 NPPV +Usual Medical Care vs Usual Medical Care ‐ Overall, Outcome 14 PaO2 kPa ‐ 1 hour post intervention (without Avdeev and Celikel studies).

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Analysis 1.15

Comparison 1 NPPV +Usual Medical Care vs Usual Medical Care ‐ Overall, Outcome 15 Respiratory Rate (bpm) ‐ 1 hour post intervention.

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Analysis 2.1

Comparison 2 NPPV + Usual Medical Care vs Usual Medical Care ‐ Admission pH subgroups, Outcome 1 Treatment failure.

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Analysis 2.2

Comparison 2 NPPV + Usual Medical Care vs Usual Medical Care ‐ Admission pH subgroups, Outcome 2 Mortality.

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Analysis 2.3

Comparison 2 NPPV + Usual Medical Care vs Usual Medical Care ‐ Admission pH subgroups, Outcome 3 Intubation.

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Analysis 2.4

Comparison 2 NPPV + Usual Medical Care vs Usual Medical Care ‐ Admission pH subgroups, Outcome 4 Length of hospital stay (days).

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Analysis 2.5

Comparison 2 NPPV + Usual Medical Care vs Usual Medical Care ‐ Admission pH subgroups, Outcome 5 Length of ICU stay (days).

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Analysis 2.6

Comparison 2 NPPV + Usual Medical Care vs Usual Medical Care ‐ Admission pH subgroups, Outcome 6 Complications of treatment.

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Analysis 2.7

Comparison 2 NPPV + Usual Medical Care vs Usual Medical Care ‐ Admission pH subgroups, Outcome 7 Respiratory Rate (bpm) ‐ 1 hour post intervention.

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Analysis 3.1

Comparison 3 NPPV + Usual Medical Care vs Usual Medical Care ‐ Trial location subgroups, Outcome 1 Treatment failure.

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Analysis 3.2

Comparison 3 NPPV + Usual Medical Care vs Usual Medical Care ‐ Trial location subgroups, Outcome 2 Mortality.

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Analysis 3.3

Comparison 3 NPPV + Usual Medical Care vs Usual Medical Care ‐ Trial location subgroups, Outcome 3 Intubation.

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Analysis 3.4

Comparison 3 NPPV + Usual Medical Care vs Usual Medical Care ‐ Trial location subgroups, Outcome 4 Length of hospital stay (days).

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Analysis 3.5

Comparison 3 NPPV + Usual Medical Care vs Usual Medical Care ‐ Trial location subgroups, Outcome 5 Length of hospital stay (days) ‐ without Avdeev study.

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Analysis 3.6

Comparison 3 NPPV + Usual Medical Care vs Usual Medical Care ‐ Trial location subgroups, Outcome 6 Complications of treatment.

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Analysis 3.7

Comparison 3 NPPV + Usual Medical Care vs Usual Medical Care ‐ Trial location subgroups, Outcome 7 Respiratory Rate (bpm) ‐ 1 hour post intervention.

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Table 1. Percentage change in PaCO2 one hour after start of intervention

Study	NPPV Admission (SD)	NPPV 1 hour (SD)	% change	UMC Admission (SD)	UMC 1 hour (SD)	% change
Avdeev1998	8.45 (1.45)	7.09 (1.43)	‐16.09	8.65 (1.29)	9.52 (1.36)	10.06
Bott 1993	8.63 (1.41)	7.39 (1.05)	‐14.37	8.61 (1.67)	8.65 (2.09)	0.46
Brochard 1995	9.33 (1.60)	9.07 (1.73)	‐2.79	8.90 (2.13)	9.60 (2.40)	7.87
Celikel 1996	9.17 (2.02)	8.53 (2.04)	‐6.98	8.88 (1.41)	8.83 (1.44)	‐0.56
Dikensoy 2002	10.45 (1.29)	10.12 (2.40)	‐3.16	8.57 (1.12)	8.88 (1.80)	3.62
Plant 2000	8.82 (1.51)	8.18 (2.00)	‐7.26	8.64 (1.70)	8.45 (1.91)	‐2.20
Barbe 1996	7.7			8.2
Conti 2002	11.33	10.00	‐11.74	11.60	7.70	‐33.60
Kramer 1995	10.79			10.75
Thys 2002	7.88			9.17
Zhou 2001	9.28			8.71

Average			‐8.91%			‐2.05%

Table 1. Percentage change in PaCO2 one hour after start of intervention

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Comparison 1. NPPV +Usual Medical Care vs Usual Medical Care ‐ Overall

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Treatment failure Show forest plot	8	541	Risk Ratio (M‐H, Fixed, 95% CI)	0.48 [0.37, 0.63]

2 Mortality Show forest plot	10	622	Risk Ratio (M‐H, Fixed, 95% CI)	0.52 [0.35, 0.76]

3 Intubation Show forest plot	14	758	Risk Ratio (M‐H, Fixed, 95% CI)	0.42 [0.33, 0.53]

4 Length of hospital stay (days) Show forest plot	8	546	Mean Difference (IV, Fixed, 95% CI)	‐3.24 [‐4.42, ‐2.06]

5 Length of ICU stay (days) Show forest plot	3	71	Mean Difference (IV, Fixed, 95% CI)	‐4.71 [‐9.59, 0.16]

6 Complications of treatment Show forest plot	3	191	Risk Ratio (M‐H, Fixed, 95% CI)	0.38 [0.24, 0.60]

7 Symptom scores (higher score means more dyspnoea) Show forest plot	2		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

7.1 Borg score	1	24	Mean Difference (IV, Fixed, 95% CI)	‐0.31 [‐1.42, 0.80]
7.2 Visual Analogue Scale	1	60	Mean Difference (IV, Fixed, 95% CI)	‐2.11 [‐3.32, ‐0.90]
8 pH 1 hour post intervention Show forest plot	7	515	Mean Difference (IV, Fixed, 95% CI)	0.01 [‐0.00, 0.02]

9 pH 1 hour post intervention (without Avdeev and Conti studies) Show forest plot	5	408	Mean Difference (IV, Fixed, 95% CI)	0.03 [0.02, 0.04]

10 PaCO2 kPa ‐ 1 hour post intervention Show forest plot	7	515	Mean Difference (IV, Fixed, 95% CI)	‐0.40 [‐0.70, ‐0.09]

11 PaCO2 kPa ‐ 1 hour post intervention (without Avdeev and Conti studies) Show forest plot	5	408	Mean Difference (IV, Fixed, 95% CI)	‐0.40 [‐0.78, ‐0.03]

12 PaO2 kPa ‐ 1 hour post intervention Show forest plot	6	466	Mean Difference (IV, Random, 95% CI)	1.22 [0.08, 2.35]

13 PaO2 kPa ‐ 1 hour post intervention (without Avdeev study) Show forest plot	5	408	Mean Difference (IV, Random, 95% CI)	0.82 [‐0.13, 1.77]

14 PaO2 kPa ‐ 1 hour post intervention (without Avdeev and Celikel studies) Show forest plot	4	378	Mean Difference (IV, Fixed, 95% CI)	0.27 [‐0.26, 0.79]

15 Respiratory Rate (bpm) ‐ 1 hour post intervention Show forest plot	5	380	Mean Difference (IV, Fixed, 95% CI)	‐3.08 [‐4.26, ‐1.89]

Comparison 1. NPPV +Usual Medical Care vs Usual Medical Care ‐ Overall

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Comparison 2. NPPV + Usual Medical Care vs Usual Medical Care ‐ Admission pH subgroups

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Treatment failure Show forest plot	8		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

1.1 Admission pH between 7.35 ‐ 7.30	3	320	Risk Ratio (M‐H, Fixed, 95% CI)	0.63 [0.43, 0.95]
1.2 Admission pH below 7.30	5	221	Risk Ratio (M‐H, Fixed, 95% CI)	0.37 [0.25, 0.54]
2 Mortality Show forest plot	8		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

2.1 Admission pH between 7.35 ‐ 7.30	3	316	Risk Ratio (M‐H, Fixed, 95% CI)	0.45 [0.26, 0.80]
2.2 Admission pH below 7.30	5	256	Risk Ratio (M‐H, Fixed, 95% CI)	0.51 [0.29, 0.90]
3 Intubation Show forest plot	11		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

3.1 Admission pH between 7.35 ‐ 7.30	3	316	Risk Ratio (M‐H, Fixed, 95% CI)	0.54 [0.32, 0.89]
3.2 Admission pH below 7.30	8	351	Risk Ratio (M‐H, Fixed, 95% CI)	0.40 [0.30, 0.53]
4 Length of hospital stay (days) Show forest plot	8		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

4.1 Admission pH between 7.35 ‐ 7.30	3	316	Mean Difference (IV, Fixed, 95% CI)	‐0.89 [‐2.92, 1.14]
4.2 Admission pH below 7.30	5	230	Mean Difference (IV, Fixed, 95% CI)	‐4.43 [‐5.88, ‐2.98]
5 Length of ICU stay (days) Show forest plot	3	71	Mean Difference (IV, Fixed, 95% CI)	‐4.71 [‐9.59, 0.16]

5.1 Admission pH below 7.30	3	71	Mean Difference (IV, Fixed, 95% CI)	‐4.71 [‐9.59, 0.16]
6 Complications of treatment Show forest plot	3		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

6.1 Admission pH below 7.30	3	191	Risk Ratio (M‐H, Fixed, 95% CI)	0.38 [0.24, 0.60]
7 Respiratory Rate (bpm) ‐ 1 hour post intervention Show forest plot	5		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

7.1 Admission pH between 7.35 ‐ 7.30	1	182	Mean Difference (IV, Fixed, 95% CI)	‐1.74 [‐3.31, ‐0.17]
7.2 Admission pH below 7.30	4	198	Mean Difference (IV, Fixed, 95% CI)	‐4.86 [‐6.67, ‐3.05]

Comparison 2. NPPV + Usual Medical Care vs Usual Medical Care ‐ Admission pH subgroups

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Comparison 3. NPPV + Usual Medical Care vs Usual Medical Care ‐ Trial location subgroups

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Treatment failure Show forest plot	8		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

1.1 Intensive Care Unit	3	127	Risk Ratio (M‐H, Fixed, 95% CI)	0.29 [0.18, 0.47]
1.2 Ward	5	414	Risk Ratio (M‐H, Fixed, 95% CI)	0.61 [0.44, 0.86]
2 Mortality Show forest plot	9		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

2.1 Intensive Care Unit	4	174	Risk Ratio (M‐H, Fixed, 95% CI)	0.61 [0.32, 1.18]
2.2 Ward	5	408	Risk Ratio (M‐H, Fixed, 95% CI)	0.43 [0.26, 0.71]
3 Intubation Show forest plot	13		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

3.1 Intensive Care Unit	6	209	Risk Ratio (M‐H, Fixed, 95% CI)	0.38 [0.27, 0.52]
3.2 Ward	7	509	Risk Ratio (M‐H, Fixed, 95% CI)	0.48 [0.34, 0.70]
4 Length of hospital stay (days) Show forest plot	8		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

4.1 Intensive Care Unit	3	138	Mean Difference (IV, Fixed, 95% CI)	‐3.38 [‐6.09, ‐0.67]
4.2 Ward	5	408	Mean Difference (IV, Fixed, 95% CI)	‐3.20 [‐4.51, ‐1.89]
5 Length of hospital stay (days) ‐ without Avdeev study Show forest plot	7		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

5.1 Intensive Care Unit	3	138	Mean Difference (IV, Fixed, 95% CI)	‐3.38 [‐6.09, ‐0.67]
5.2 Ward	4	350	Mean Difference (IV, Fixed, 95% CI)	‐2.75 [‐4.12, ‐1.37]
6 Complications of treatment Show forest plot	3		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

6.1 Intensive Care Unit	2	133	Risk Ratio (M‐H, Fixed, 95% CI)	0.43 [0.25, 0.74]
6.2 Ward	1	58	Risk Ratio (M‐H, Fixed, 95% CI)	0.29 [0.13, 0.69]
7 Respiratory Rate (bpm) ‐ 1 hour post intervention Show forest plot	5	380	Mean Difference (IV, Fixed, 95% CI)	‐3.08 [‐4.26, ‐1.89]

7.1 Intensive Care Unit	2	108	Mean Difference (IV, Fixed, 95% CI)	‐5.39 [‐7.96, ‐2.81]
7.2 Ward	3	272	Mean Difference (IV, Fixed, 95% CI)	‐2.46 [‐3.79, ‐1.13]

Comparison 3. NPPV + Usual Medical Care vs Usual Medical Care ‐ Trial location subgroups

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