Association of noninvasive respiratory support with mortality and intubation rates in acute respiratory failure: a systematic review and network meta-analysis

Abstract

Background: Noninvasive respiratory support devices may reduce the tracheal intubation rate compared with conventional oxygen therapy (COT). To date, few studies have compared high-flow nasal cannula (HFNC) use with noninvasive positive-pressure ventilation (NPPV). We conducted a network meta-analysis to compare the effectiveness of three respiratory support devices in patients with acute respiratory failure. Methods: The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and Ichushi databases were searched. Studies including adults aged ≥ 16 years with acute hypoxic respiratory failure and randomized-controlled trials that compared two different oxygenation devices (COT, NPPV, or HFNC) before tracheal intubation were included. A frequentist-based approach with a multivariate random-effects meta-analysis was used. The network meta-analysis was performed using the GRADE Working Group approach. The outcomes were short-term mortality and intubation rate. Results: Among 5507 records, 27 studies (4618 patients) were included. The main cause of acute hypoxic respiratory failure was pneumonia. Compared with COT, NPPV and HFNC use tended to reduce mortality (relative risk, 0.88 and 0.93, respectively; 95% confidence intervals, 0.76–1.01 and 0.80–1.08, respectively; both low certainty) and lower the risk of endotracheal intubation (0.81 and 0.78; 0.72–0.91 and 0.68–0.89, respectively; both low certainty); however, short-term mortality or intubation rates did not differ (0.94 and 1.04, respectively; 0.78–1.15 and 0.88–1.22, respectively; both low certainty) between NPPV and HFNC use. Conclusion: NPPV and HFNC use are associated with a decreased risk of endotracheal intubation; however, there are no significant differences in short-term mortality. Trial registration: PROSPERO (registration number: CRD42020139105, 01/21/2020)