Noninvasive ventilation as a weaning strategy for mechanical ventilation in adults with respiratory failure: a Cochrane systematic review

Background: Noninvasive ventilation has been studied as a means of reducing complications among patients being weaned from invasive mechanical ventilation. We sought to summarize evidence comparing noninvasive and invasive weaning and their effects on mortality. Methods: We identified relevant randomized and quasirandomized trials through searches of databases, conference proceedings and grey literature. We included trials comparing extubation and immediate application of noninvasive ventilation with continued invasive weaning in adults on mechanical ventilation. Two reviewers each independently screened citations, assessed trial quality and abstracted data. Our primary outcome was mortality. Results: We identified 16 trials involving 994 participants, most of whom had chronic obstructive pulmonary disease (COPD). Compared with invasive weaning, noninvasive weaning significantly reduced mortality (risk ratio [RR] 0.53, 95% confidence interval [CI] 0.36 to 0.80), weaning failures (RR 0.63, 95% CI 0.42 to 0.96), ventilator-associated pneumonia (RR 0.25, 95% CI 0.15 to 0.43), length of stay in the intensive care unit (mean difference [MD] −5.59 d, 95% CI −7.90 to −3.28) and in hospital (MD −6.04 d, 95% CI −9.22 to −2.87), and total duration of mechanical ventilation (MD −5.64 d, 95% CI −9.50 to −1.77). Noninvasive weaning had no significant effect on the duration of ventilation related to weaning, but significantly reduced rates of tracheostomy (RR 0.19, 95% CI 0.08 to 0.47) and reintubation (RR 0.65, 95% CI 0.44 to 0.97). Mortality benefits were significantly greater in trials enrolling patients with COPD than in trials enrolling mixed patient populations (RR 0.36 [95% CI 0.24 to 0.56] v. RR 0.81 [95% CI 0.47 to 1.40]). Interpretation: Noninvasive weaning reduces rates of death and pneumonia without increasing the risk of weaning failure or reintubation. In subgroup analyses, mortality benefits were significantly greater in patients with COPD.

[1]  T C Chalmers,et al.  A comparison of statistical methods for combining event rates from clinical trials. , 1989, Statistics in medicine.

[2]  B. Mokhlesi,et al.  Noninvasive ventilation for persistent weaning failure. , 2004, American journal of respiratory and critical care medicine.

[3]  S. Vieira,et al.  Noninvasive mechanical ventilation may be useful in treating patients who fail weaning from invasive mechanical ventilation: a randomized clinical trial , 2008, Critical care.

[4]  C. Girault,et al.  Noninvasive ventilation as a systematic extubation and weaning technique in acute-on-chronic respiratory failure: a prospective, randomized controlled study. , 1999, American journal of respiratory and critical care medicine.

[5]  Ann D. Zeigler,et al.  Respiratory infection complicating long-term tracheostomy. The implication of persistent gram-negative tracheobronchial colonization. , 1984, Chest.

[6]  Wei,et al.  Pulmonary infection control window in treatment of severe respiratory failure of chronic obstructive pulmonary diseases: a prospective, randomized controlled, multi-centred study. , 2005, Chinese medical journal.

[7]  G. Guyatt,et al.  GRADE: an emerging consensus on rating quality of evidence and strength of recommendations , 2008, BMJ : British Medical Journal.

[8]  W. G. Cochran.  The combination of estimates from different experiments. , 1954 .

[9]  S K Pingleton,et al.  Complications of acute respiratory failure. , 1988, The Medical clinics of North America.

[10]  D. Cook,et al.  Clinical practice guidelines for the use of noninvasive positive-pressure ventilation and noninvasive continuous positive airway pressure in the acute care setting , 2011, Canadian Medical Association Journal.

[11]  M. Antonelli,et al.  Noninvasive ventilation after early extubation in patients recovering from hypoxemic acute respiratory failure: a single-centre feasibility study , 2012, Intensive Care Medicine.

[12]  D Hess,et al.  Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. , 2001, Chest.

[13]  杨毅,et al.  Prospective randomized controlled clinical study of sequential non-invasive following invasive mechanical ventilation in patients with acute respiratory failure induced by COPD , 2005 .

[14]  D. Moher,et al.  Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. , 2010, International journal of surgery.

[15]  S. Nava,et al.  Effect of nasal pressure support ventilation and external PEEP on diaphragmatic activity in patients with severe stable COPD. , 1993, Chest.

[16]  M. S. Patel,et al.  An introduction to meta-analysis. , 1989, Health Policy.

[17]  C F Donner,et al.  Physiologic effects of positive end-expiratory pressure and mask pressure support during exacerbations of chronic obstructive pulmonary disease. , 1994, American journal of respiratory and critical care medicine.

[18]  R. Khanna,et al.  Role of noninvasive ventilation in weaning from mechanical ventilation in patients of chronic obstructive pulmonary disease: An Indian experience , 2009, Indian journal of critical care medicine : peer-reviewed, official publication of Indian Society of Critical Care Medicine.

[19]  J. Moran,et al.  Noninvasive ventilation in acute respiratory failure--a meta-analysis update. , 2002, Critical care medicine.

[20]  M. Antonelli,et al.  A Comparison of Noninvasive Positive-Pressure Ventilation and Conventional Mechanical Ventilation in Patients with Acute Respiratory Failure , 1998 .

[21]  Yang Yi.  Prospective randomized controlled clinical study of sequential non-invasive following invasive mechanical ventilation in patients with acute respiratory failure induced by COPD , 2005 .

[22]  X. Xiang,et al.  [Application of sequential noninvasive following invasive mechanical ventilation in COPD patients with severe respiratory failure by investigating the appearance of pulmonary-infection-control-window]. , 2006, Zhong nan da xue xue bao. Yi xue ban = Journal of Central South University. Medical sciences.

[23]  G. Guyatt,et al.  Are the recommendations to use perioperative β-blocker therapy in patients undergoing noncardiac surgery based on reliable evidence? , 2004, Canadian Medical Association Journal.

[24]  M. Meade,et al.  Use of non-invasive ventilation to wean critically ill adults off invasive ventilation: meta-analysis and systematic review , 2009, BMJ : British Medical Journal.

[25]  Kristian Thorlund,et al.  The Number of Patients and Events Required to Limit the Risk of Overestimation of Intervention Effects in Meta-Analysis—A Simulation Study , 2011, PloS one.

[26]  B. Schorn,et al.  The influence of controlled mandatory ventilation (CMV), intermittent mandatory ventilation (IMV) and biphasic intermittent positive airway pressure (BIPAP) on duration of intubation and consumption of analgesics and sedatives. A prospective analysis in 596 patients following adult cardiac surgery. , 1997, European journal of anaesthesiology.

[27]  D. Cook,et al.  The attributable morbidity and mortality of ventilator-associated pneumonia in the critically ill patient. The Canadian Critical Trials Group. , 1999, American journal of respiratory and critical care medicine.

[28]  G. Mills,et al.  Non-invasive ventilation for weaning, avoiding reintubation after extubation and in the postoperative period: a meta-analysis. , 2012, British journal of anaesthesia.

[29]  M. Drent,et al.  Presence of human metapneumovirus in bronchoalveolar lavage fluid samples detected by means of real-time polymerase chain reaction , 2008, Critical Care.

[30]  K. Nourdine,et al.  Does noninvasive ventilation reduce the ICU nosocomial infection risk? A prospective clinical survey , 1999, Intensive Care Medicine.

[31]  J. Chen,et al.  [Time for extubation and sequential noninvasive mechanical ventilation in COPD patients with exacerbated respiratory failure who received invasive ventilation]. , 2001, Zhonghua jie he he hu xi za zhi = Zhonghua jiehe he huxi zazhi = Chinese journal of tuberculosis and respiratory diseases.

[32]  S. Thompson,et al.  Quantifying heterogeneity in a meta‐analysis , 2002, Statistics in medicine.

[33]  G. Criner,et al.  Overview of improving tolerance of long-term mechanical ventilation. , 1994, Critical care clinics.

[34]  Y. Mehta,et al.  Ventilator-associated pneumonia: Incidence, risk factors, outcome, and microbiology. , 2003, Journal of cardiothoracic and vascular anesthesia.

[35]  G. Rabie,et al.  Noninvasive Ventilation in the Weaning of Patients With Acute-on-Chronic Respiratory Failure Due to COPD , 2004 .

[36]  D. Cook,et al.  Which Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease Benefit from Noninvasive Positive-Pressure Ventilation? , 2003, Annals of Internal Medicine.

[37]  A. Fischman,et al.  Does whole-body 2-[18F]-fluoro-2-deoxy-D-glucose positron emission tomography have an advantage over thoracic positron emission tomography for staging patients with lung cancer? , 2004, Chest.

[38]  Ali Mohamed Ali Elnabtity,et al.  Noninvasive proportional assist ventilation may be useful in weaning patients who failed spontaneous breathing trial , 2012 .

[39]  J. Benichou,et al.  Noninvasive ventilation and weaning in patients with chronic hypercapnic respiratory failure: a randomized multicenter trial. , 2011, American journal of respiratory and critical care medicine.

[40]  H Fabel,et al.  [Noninvasive ventilation]. , 2000, Der Internist.

[41]  R. Rodríguez-Roisín,et al.  Noninvasive ventilation during persistent weaning failure: a randomized controlled trial. , 2003, American journal of respiratory and critical care medicine.

[42]  A. Simonds,et al.  Nasal ventilation to facilitate weaning in patients with chronic respiratory insufficiency. , 1992, Thorax.

[43]  G Sherman,et al.  Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. , 1999, Critical care medicine.