Noninvasive Ventilation as a Weaning Strategy in Subjects with Acute Hypoxemic Respiratory Failure

Abstract

BACKGROUND: Weaning through noninvasive ventilation (NIV) after early extubation may facilitate invasive ventilation withdrawal and reduce related complications in patients with hypercapnic respiratory failure. However, the effects of NIV weaning are uncertain in patients with acute hypoxemic respiratory failure (AHRF). We aimed to investigate whether NIV weaning could reduce hospital mortality and other outcomes compared with invasive weaning in subjects with hypoxemic AHRF. METHODS: We searched medical literature databases for relevant articles published from inception to February 2019. Randomized controlled trials that adopted NIV as a weaning strategy compared with invasive weaning in hypoxemic AHRF were included. The primary outcome was hospital mortality. The secondary outcomes included ICU mortality, the ICU stay, weaning time, duration of ventilation, extubation failure, and adverse events. RESULTS: Six relevant studies, which involved 718 subjects, were included. There was no significant effect of NIV weaning on hospital mortality compared with invasive weaning (risk ratio 0.94, 95% CI 0.65-1.36; P 5 .74), whereas there was a significant effect of NIV weaning on shortening the ICU stay (mean difference 23.95, 95% CI 26.49 to 21.40, P 5 .002) and on decreasing adverse events without affecting the weaning time (standardized MD 20.04, 95% CI 20.21 to 0.14; P 5 .68). CONCLUSIONS: The strategy of NIV weaning did not decrease hospital mortality in subjects with hypoxemic AHRF, but it did shorten the ICU lengths of stay and reduce adverse events.

Actualización de las recomendaciones del proyecto Neumonía Zero

“…Más recientemente, Yeung et al 31 , en una revisión sistemática donde se analizan los protocolos de destete con aplicación de ventilación no invasiva (VNI), describen una reducción significativa en el tiempo de VM, de estancia en UCI y de mortalidad y también una reducción en la incidencia de NAVM. En esta misma línea se han publicado otros dos estudios posteriores a la revisión sistemática 32 , 33 .…”

The authors respond

“…Further, the graphic representation is highly recommended to avoid misunderstanding of the data, as we have done. 2 Looking at the figures, 2 facts are clear: (1) The loss of lung function is associated with reductions of the diaphragmatic mobility during the deep inspiration maneuvers; (2) the loss of lung function is associated with the increases of the diaphragmatic mobility during rest breathing. Those associations were extensively discussed in paragraphs 1 and 5 of the discussion.…”

“…In a review of 6 randomized controlled trials (RCTs) with moderate-to-high risk of bias, the authors stated that there was no effect of NIV weaning on hospital and ICU mortality even if it reduced the length of ICU stay and adverse events compared with invasive weaning in acute hypoxemic respiratory failure. 2 The fragility index (FI), an intuitive measure of the robustness of RCTs, was recently introduced in critical care medicine and has been used in several different systematic reviews. [3][4][5] The FI is achieved by using a 2-by-2 contingency table and P values produced with the Fisher exact test.…”

“…[3][4][5] The FI is achieved by using a 2-by-2 contingency table and P values produced with the Fisher exact test. 3 We calculated the FI of RCTs included in the systematic review by Shan et al 2 and that all of the included studies had a FI of zero (FI ¼ 0 and P > .05). This FI score means that the RCTs evaluating the use of NIV weaning on mortality are very fragile and the evidence from these studies is very weak.…”

Effect of hydrocolloid dressing on pressure ulcer in patients with non‐invasive positive pressure ventilation: A meta‐analysis

“…NIPPV uses a mask to provide positive pressure ventilation, aiding patients with respiratory failure by improving alveolar ventilation, reducing the effort required for breathing and avoiding the complications associated with endotracheal intubation. This approach reduces the incidence of ventilator‐associated pneumonia and shortens hospital stay 3 . However, prolonged mask use carries the risk of facial soft tissue rupture because of persistent tissue deformation caused by the rigid mask surface and the humid environment.…”