Efficacy of non-invasive and invasive respiratory management strategies in adult patients with acute hypoxaemic respiratory failure: a systematic review and network meta-analysis

Abstract

Background: Although non-invasive respiratory management strategies have been implemented to avoid intubation, patients with de novo acute hypoxaemic respiratory failure (AHRF) are high risk of treatment failure. In the previous meta-analyses, the effect of non-invasive ventilation was not evaluated according to ventilation modes in those patients. Furthermore, no meta-analyses comparing non-invasive respiratory management strategies with invasive mechanical ventilation (IMV) have been reported. We performed a network meta-analysis to compare the efficacy of non-invasive ventilation according to ventilation modes with high-flow nasal oxygen (HFNO), standard oxygen therapy (SOT), and IMV in adult patients with AHRF.

Methods: The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and Ichushi databases were searched. Studies including adults with AHRF and randomized controlled trials (RCTs) comparing two different respiratory management strategies (continuous positive airway pressure (CPAP), pressure support ventilation (PSV), HFNO, SOT, or IMV) were reviewed.

Results: We included 25 RCTs (3,302 participants: 27 comparisons). Using SOT as the reference, CPAP (risk ratio [RR] 0.55; 95% confidence interval [CI] 0.31-0.95; very low certainty) was associated significantly with a lower risk of mortality. Compared with SOT, PSV (RR 0.81; 95% CI 0.62-1.06; low certainty) and HFNO (RR 0.90; 95% CI 0.65-1.25; very low certainty) were not associated with a significantly lower risk of mortality. Compared with IMV, no non-invasive respiratory management was associated with a significantly lower risk of mortality, although all certainties of evidence were very low. The probability of being best in reducing short-term mortality among all possible interventions was higher for CPAP, followed by PSV and HFNO; IMV and SOT were tied for the worst (surface under the cumulative ranking curve value: 93.2, 65.0, 44.1, 23.9, and 23.9, respectively).

Conclusions: When performing non-invasive ventilation among patients with de novo AHRF, it is important to avoid excessive tidal volume and lung injury. Although pressure support is needed for some of these patients, it should be applied with caution because this may lead to excessive tidal volume and lung injury. Trial registration protocols.io (Protocol integer ID 49375, April 23, 2021). https://doi.org/10.17504/protocols.io.buf7ntrn .

Keywords: Acute hypoxaemic respiratory failure; Continuous positive airway pressure; High-flow nasal oxygen; Network meta-analysis; Non-invasive ventilation.

Fig. 1

Flow diagram of studies included in this review. *Ichushi is a database of Japanese research papers. CENTRAL, Cochrane Central Register of Controlled Trials; CPAP, continuous positive airway pressure; HFNO, high-flow nasal oxygen; IMV, invasive mechanical ventilation; PSV, pressure support ventilation; RCT, randomized controlled trial; RR, risk ratio; SOT, standard oxygen therapy

Fig. 2

Network plot for non-invasive respiratory management strategies for adults with AHRF. a For the primary outcome, short-term mortality, the longest follow-up was up to 100 days. b Secondary outcome, endotracheal intubation. When RCTs for direct comparisons exist, this is shown by connections between nodes. The size of the node represents the number of participants who received the intervention. The thickness of lines connecting nodes represents the number of trials for that comparison. CPAP, continuous positive airway pressure; HFNO, high-flow nasal oxygen; IMV, invasive mechanical ventilation; PSV, pressure support ventilation; RCT, randomized controlled trial; SOT, standard oxygen therapy

Fig. 3

Forest plots for association of non-invasive respiratory management strategies with study outcomes. a For the primary outcome, short-term mortality, the longest follow-up was up to 100 days. b Secondary outcome, endotracheal intubation. All outcomes are reported as network risk ratios and absolute risk differences with 95% CIs. For estimating risk ratios for the comparison of HFNO vs IMV, CPAP vs IMV, CPAP vs HFNO, and CPAP vs PSV, only indirect evidence was used, because no direct pair-wise comparisons were available. The estimated absolute risks of mortality and endotracheal intubation were 30% and 40%, respectively, in the control group. CI, confidence interval; CPAP, continuous positive airway pressure; HFNO, high-flow nasal oxygen; IMV, invasive mechanical ventilation; PSV, pressure support ventilation; RR, risk ratio; SOT, standard oxygen therapy