Effects of non-invasive respiratory support in post-operative patients: a systematic review and network meta-analysis

Abstract

Background: Re-intubation secondary to post-extubation respiratory failure in post-operative patients is associated with increased patient morbidity and mortality. Non-invasive respiratory support (NRS) alternative to conventional oxygen therapy (COT), i.e., high-flow nasal oxygen, continuous positive airway pressure, and non-invasive ventilation (NIV), has been proposed to prevent or treat post-extubation respiratory failure. Aim of the present study is assessing the effects of NRS application, compared to COT, on the re-intubation rate (primary outcome), and time to re-intubation, incidence of nosocomial pneumonia, patient discomfort, intensive care unit (ICU) and hospital length of stay, and mortality (secondary outcomes) in adult patients extubated after surgery.

Methods: A systematic review and network meta-analysis of randomized and non-randomized controlled trials. A search from Medline, Embase, Scopus, Cochrane Central Register of Controlled Trials, and Web of Science from inception until February 2, 2024 was performed.

Results: Thirty-three studies (11,292 patients) were included. Among all NRS modalities, only NIV reduced the re-intubation rate, compared to COT (odds ratio 0.49, 95% confidence interval 0.28; 0.87, p = 0.015, I² = 60.5%, low certainty of evidence). In particular, this effect was observed in patients receiving NIV for treatment, while not for prevention, of post-extubation respiratory failure, and in patients at high, while not low, risk of post-extubation respiratory failure. NIV reduced the rate of nosocomial pneumonia, ICU length of stay, and ICU, hospital, and long-term mortality, while not worsening patient discomfort.

Conclusions: In post-operative patients receiving NRS after extubation, NIV reduced the rate of re-intubation, compared to COT, when used for treatment of post-extubation respiratory failure and in patients at high risk of post-extubation respiratory failure.

Keywords: Continuous positive airway pressure; Conventional oxygen therapy; Extubation; General anesthesia; High-flow nasal oxygen; Non-invasive ventilation; Post-operative respiratory failure.

Fig. 1

Study selection flow-chart. Abbreviations: NRS non-invasive respiratory support; RCT randomized controlled trial

Fig. 2

Risk of bias assessment figures for randomized (A) and non-randomized (B) controlled trials. For randomized controlled trials, green, yellow, and red circles indicate low risk of bias, some concerns, and high risk of bias, respectively. For non-randomized controlled trials, green, yellow, red, and grey circles indicate low, moderate, serious, and critical risk of bias, respectively

Fig. 3

Forest plots of the effect of non-invasive respiratory support on primary and secondary outcomes. Abbreviations: COT conventional oxygen therapy; NRS non-invasive respiratory support; OR odds ratio; CI confidence interval; CPAP continuous positive airway pressure; NIV non-invasive ventilation; HFNO high-flow nasal oxygen; ICU intensive care unit; SMD standardized mean difference