Non-invasive ventilation versus invasive weaning in critically ill adults: a systematic review and meta-analysis

Abstract

BackgroundExtubation to non-invasive ventilation (NIV) has been investigated as a strategy to wean critically ill adults from invasive ventilation and reduce ventilator-related complications.MethodsWe searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, proceedings of four conferences and bibliographies (to June 2020) for randomised and quasi-randomised trials that compared extubation with immediate application of NIV to continued invasive weaning in intubated adults and reported mortality (primary outcome) or other outcomes. Two reviewers independently screened citations, assessed trial quality and abstracted data.ResultsWe identified 28 trials, of moderate-to-good quality, involving 2066 patients, 44.6% with chronic obstructive pulmonary disease (COPD). Non-invasive weaning significantly reduced mortality (risk ratio (RR) 0.57, 95% CI 0.44 to 0.74; high quality), weaning failures (RR 0.59, 95% CI 0.43 to 0.81; high quality), pneumonia (RR 0.30, 95% CI 0.22 to 0.41; high quality), intensive care unit (ICU) (mean difference (MD) −4.62 days, 95% CI −5.91 to −3.34) and hospital stay (MD −6.29 days, 95% CI −8.90 to −3.68). Non-invasive weaning also significantly reduced the total duration of ventilation, duration of invasive ventilation and duration of ventilation related to weaning (MD −0.57, 95% CI −1.08 to −0.07) and tracheostomy rate. Mortality, pneumonia, reintubation and ICU stay were significantly lower in trials enrolling COPD (vs mixed) populations.ConclusionNon-invasive weaning significantly reduced mortality, pneumonia and the duration of ventilation related to weaning, particularly in patients with COPD. Beneficial effects are less clear (or more careful patient selection is required) in non-COPD patients.PROSPERO registration numberCRD42020201402.

Noninvasive respiratory support following extubation in critically ill adults: a systematic review and network meta-analysis

“…This reduction in reintubation likely contributed to the lower incidence of VAP among patients receiving noninvasive ventilation. Previous work comparing the use NIPPV during weaning against invasive ventilation has demonstrated its superiority in reducing mortality, while preventing weaning failure and reducing ICU length of stay [74]. Our review builds upon this existing work, and shows that NIPPV is likely superior to conventional oxygen therapy in reducing reintubation in the post-extubation period.…”

Rehabilitation of Difficult-to-Wean, Tracheostomized Patients Admitted to Specialized Unit: Retrospective Analyses over 10-Years

“…It is very likely that the staff’s skills improved over time [ 17 ], thus allowing them to care for more complex patients in the intensive care unit. As a result, patients could have been treated earlier and received a more comprehensive approach to weaning [ 18 ], thereby greatly reducing the burden of prolonged care. Indeed, our retrospective analysis found that the length of stay in the weaning unit and the time to home discharge reduced slightly, although not significantly, over the entire 10-year period (data not shown).…”

Liberation from Mechanical Ventilation: Established and New Insights

“…29 A recent systematic review and meta-analysis of 28 trials (2,066 patients) compared early extubation to NIV with traditional liberation strategies and found that early extubation to NIV reduced mortality, ventilator-associated pneumonia, and weaning failures (based on high-quality evidence) and also reduced length of stay in the ICU and hospital and rates of tracheostomy. 49 Subgroup analysis suggested that the benefits of early extubation to NIV were greater in patients with COPD than in other patient populations. 49 A separate meta-analysis of five trials (525 patients) that compared preventive post-extubation NIV for high-risk patients with post-extubation without NIV (typically to low-flow oxygen) found that preventive post-extubation NIV increased extubation success and reduced ICU mortality and ICU length of stay.…”

“…49 Subgroup analysis suggested that the benefits of early extubation to NIV were greater in patients with COPD than in other patient populations. 49…”

“…A recent systematic review and meta-analysis of 28 trials (2,066 patients) compared early extubation to NIV with traditional liberation strategies and found that early extubation to NIV reduced mortality, ventilator-associated pneumonia, and weaning failures (based on high-quality evidence) and also reduced length of stay in the ICU and hospital and rates of tracheostomy. 49 Subgroup analysis suggested that the benefits of early extubation to NIV were greater in patients with COPD than in other patient populations. 49…”