Preventive use of respiratory support after scheduled extubation in critically ill medical patients—a network meta-analysis of randomized controlled trials

Abstract

Background: Respiratory support has been increasingly used after extubation for the prevention of re-intubation and improvement of prognosis in critically ill medical patients. However, the optimal respiratory support method is still under debate. This network meta-analysis (NMA) aims to evaluate the comparative effectiveness of various respiratory support methods used for preventive purposes after scheduled extubation in critically ill medical patients. Methods: A systematic database search was performed from inception to December 19, 2019, for randomized controlled trials (RCTs) that compared a preventive use of different respiratory support methods, including conventional oxygen therapy (COT), noninvasive ventilation (NIV), high-flow oxygen therapy (HFOT), and combinational use of HFOT and NIV (HFOT+NIV), after planned extubation in adult critically ill medical patients. Study selection, data extraction, and quality assessments were performed in duplicate. The primary outcomes included re-intubation rate and short-term mortality. Results: Seventeen RCTs comprising 3341 participants with 4 comparisons were included. Compared with COT, NIV significantly reduced the re-intubation rate [risk ratio (RR) 0.55, 95% confidence interval (CI) 0.39 to 0.77; moderate quality of evidence] and short-term mortality (RR 0.66, 95% CI 0.48 to 0.91; moderate quality of evidence). Compared to COT, HFOT had a beneficial effect on the re-intubation rate (RR 0.55, 95% CI 0.35 to 0.86; moderate quality of evidence) but no effect on short-term mortality (RR 0.79, 95% CI 0.56 to 1.12; low quality of evidence). No significant difference in the re-intubation rate or short-term mortality was found among NIV, HFOT, and HFOT+NIV. The treatment rankings based on the surface under the cumulative ranking curve (SUCRA) from best to worst for re-intubation rate were HFOT+NIV (95.1%), NIV (53.4%), HFOT (51.2%), and COT (0.3%), and the rankings for shortterm mortality were NIV (91.0%), HFOT (54.3%), HFOT+NIV (43.7%), and COT (11.1%). Sensitivity analyses of trials with a high risk of extubation failure for the primary outcomes indicated that the SUCRA rankings were comparable to

The Comparison of Noninvasive Ventilation, High-Flow Oxygen Therapy and Conventional Oxygen Therapy for Weaning Failure in High-Risk Patients

“…The reason for that discrepancy was explained with the insufficiency of COT to guarantee satisfactory gas exchange compared to NIV or HFO therapy and NIV was proposed to prevent reintubation and to decrease mortality rate after planned weaning as a prophylactic approach. In our study, the HFO group had the lowest reintubation and 30-day mortality rates in contrast to the Zhou et al [9] study in which NIV was found superior to HFO regarding survival benefit but not reintubation rates. This difference was explained with higher positive airway pressure and greater improvement in cardiac performance provided by the NIV technique.…”

“…Over the last two decades, NIV and later HFO have gained popularity in different clinical settings including weaning failure and they might increase end-expiratory lung volume and reduce work of breathing in principle but to what extent these benefits help to avoid the risk of weaning failure is unclear and unconvincing for some researchers especially in terms of high-risk patients [2,8,9] . The primary objective of this study was to prove if NIV or HFO is beneficial in decreasing weaning failure in high-risk patient population.…”

Post-extubation Oxygenation Strategies and Mortality and Reintubation Rates in Acute Respiratory Failure: A Systematic Review and Network Meta-Analysis

“…Zhou et al recently reported a systematic review using NMA that compared NPPV, HFNC, and COT in post-extubation patients [49], but their inclusion criteria differ from ours. Zhou et al included all studies with COPD patients, whereas we excluded studies with >50% COPD patients.…”

Post-extubation oxygenation strategies in acute respiratory failure: a systematic review and network meta-analysis

“…Zhou et al recently reported a systematic review using NMA that compared NPPV, HFNC, and COT in post-extubation patients [ 49 ], but their inclusion criteria differ from ours. Zhou et al included all studies with patients with COPD, whereas we excluded studies with > 50% COPD patients.…”