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Noninvasive Positive-Pressure Ventilation for Acute Respiratory Failure: Comparative Effectiveness

Slide: 20 of 25

Other Key Findings of the Comparative Effectiveness Review (2 of 3)

Limited evidence suggested potential benefits of noninvasive positive-pressure ventilation (NPPV) in preventing recurrent respiratory failure after extubation in high-risk patients. The strength of evidence for this finding was rated low.

  • Five studies assessing reintubation rates with NPPV (bilevel positive airway pressure in all studies) versus usual care reported reintubation rates ranging from 8–25 percent for NPPV and 8–28 percent for usual care. Overall, using NPPV after extubation did not decrease reintubation rates when compared with usual supportive care. However, subgroup analyses in patients at high risk for recurrent acute respiratory failure versus those at average risk showed a protective effect only for those at high risk (odd ratio [OR] = 0.43; 95-percent confidence interval [95% CI], 0.24 to 0.77).
  • Two studies, both in populations at high risk for reintubation, reported rates of hospital-acquired pneumonia ranging from 6–23 percent for NPPV and 17–33 percent for usual care. Overall, using NPPV after extubation decreased hospital-acquired pneumonia rates when compared with usual supportive care (summary OR = 0.52; 95% CI, 0.28 to 0.97).
  • Mortality ranged from 1–23 percent for usual care and 1–16 percent for NPPV in four studies. Overall, using NPPV after extubation did not decrease mortality (OR = 0.65; 95% CI, 0.38 to 1.10). Exploratory subgroup analyses suggested a greater effect in patients at high risk versus average risk, but the difference in effects was not statistically significant (p = 0.33).

Limited evidence also suggested that in patients with chronic obstructive pulmonary disease (COPD) who were intubated for acute respiratory failure, there was a reduction in hospital-acquired pneumonia and mortality when NPPV was used to facilitate extubation.

  • Five studies reported the effects of using NPPV to facilitate extubation versus conventional weaning on mortality. For the two studies in patients with CODP, NPPV decreased mortality (summary OR = 0.17; 95% CI, 0.05–0.65). In the three studies conducted in patients with mixed etiologies of acute respiratory failure, the number of patients randomized and events (38 deaths) were small, and the results were highly variable across studies.
  • Five studies reported the effects of using NPPV to facilitate extubation versus conventional weaning on hospital-acquired pneumonia. For the two studies in patients with COPD, NPPV decreased rates of hospital-acquired pneumonia (summary OR = 0.14; 95% CI, 0.04–0.48). In the three studies conducted in patients with mixed etiologies of acute respiratory failure, confidence intervals were broad and the number of patients studied were few.