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

Shannon M Fernando; Alexandre Tran; Behnam Sadeghirad; Karen E A Burns; Eddy Fan; Daniel Brodie; Laveena Munshi; Ewan C Goligher; Deborah J Cook; Robert A Fowler; Margaret S Herridge; Pierre Cardinal; Samir Jaber; Morten Hylander Møller; Arnaud W Thille; Niall D Ferguson; Arthur S Slutsky; Laurent J Brochard; Andrew J E Seely; Bram Rochwerg

doi:10.1007/s00134-021-06581-1

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

Intensive Care Med. 2022 Feb;48(2):137-147. doi: 10.1007/s00134-021-06581-1. Epub 2021 Nov 25.

Authors

Shannon M Fernando^{1

2}, Alexandre Tran^{3

4

5}, Behnam Sadeghirad^{6

7}, Karen E A Burns^{7

8

9}, Eddy Fan^{8

10

11

12}, Daniel Brodie^{13

14}, Laveena Munshi^{8

10

11}, Ewan C Goligher^{8

10

11

12}, Deborah J Cook^{7

15}, Robert A Fowler^{8

10

16}, Margaret S Herridge^{8

10

11

12}, Pierre Cardinal³, Samir Jaber^{17

18}, Morten Hylander Møller¹⁹, Arnaud W Thille^{20

21}, Niall D Ferguson^{8

10

11

12}, Arthur S Slutsky^{8

9}, Laurent J Brochard^{8

9}, Andrew J E Seely^#^{3

4

5

22}, Bram Rochwerg^#^{7

15}

Affiliations

¹ Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada. sfernando@qmed.ca.
² Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada. sfernando@qmed.ca.
³ Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.
⁴ Department of Surgery, University of Ottawa, Ottawa, ON, Canada.
⁵ School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
⁶ Department of Anesthesia, McMaster University, Hamilton, ON, Canada.
⁷ Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
⁸ Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
⁹ Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.
¹⁰ Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
¹¹ Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada.
¹² Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada.
¹³ Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA.
¹⁴ Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA.
¹⁵ Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada.
¹⁶ Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
¹⁷ Hôpital Saint-Eloi, Centre Hospitalier Universitaire (CHU) Montpellier, PhyMedExp, INSERM, CNRS, Montpellier, France.
¹⁸ Département de Médecine Intensive et Réanimation, Centre Hospitalier Universitaire (CHU) Montpellier, PhyMedExp, INSERM, CNRS, Montpellier, France.
¹⁹ Department of Intensive Care, Copenhagen University Righospitalet, Copenhagen, Denmark.
²⁰ Centre Hospitalier Universitaire de Poitiers, Médecine Intensive Réanimation, Poitiers, France.
²¹ INSERM Centre d'Investigation Clinique 1402, ALIVE, Université de Poitiers, Poitiers, France.
²² Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.

^# Contributed equally.

PMID: 34825256
DOI: 10.1007/s00134-021-06581-1

Abstract

Purpose: Systematic review and network meta-analysis to investigate the efficacy of noninvasive respiratory strategies, including noninvasive positive pressure ventilation (NIPPV) and high-flow nasal cannula (HFNC), in reducing extubation failure among critically ill adults.

Methods: We searched databases from inception through October 2021 for randomized controlled trials (RCTs) evaluating noninvasive respiratory support therapies (NIPPV, HFNC, conventional oxygen therapy, or a combination of these) following extubation in critically ill adults. Two reviewers performed screening, full text review, and extraction independently. The primary outcome of interest was reintubation. We used GRADE to rate the certainty of our findings.

Results: We included 36 RCTs (6806 patients). Compared to conventional oxygen therapy, NIPPV (OR 0.65 [95% CI 0.52-0.82]) and HFNC (OR 0.63 [95% CI 0.45-0.87]) reduced reintubation (both moderate certainty). Sensitivity analyses showed that the magnitude of the effect was highest in patients with increased baseline risk of reintubation. As compared to HFNC, no difference in incidence of reintubation was seen with NIPPV (OR 1.04 [95% CI 0.78-1.38], low certainty). Compared to conventional oxygen therapy, neither NIPPV (OR 0.8 [95% CI 0.61-1.04], moderate certainty) or HFNC (OR 0.9 [95% CI 0.66-1.24], low certainty) reduced short-term mortality. Consistent findings were demonstrated across multiple subgroups, including high- and low-risk patients. These results were replicated when evaluating noninvasive strategies for prevention (prophylaxis), but not in rescue (application only after evidence of deterioration) situations.

Conclusions: Our findings suggest that both NIPPV and HFNC reduced reintubation in critically ill adults, compared to conventional oxygen therapy. NIPPV did not reduce incidence of reintubation when compared to HFNC. These findings support the preventative application of noninvasive respiratory support strategies to mitigate extubation failure in critically ill adults, but not in rescue conditions.

Keywords: Critical care medicine; Extubation failure; High-flow nasal cannula; Mechanical ventilation.

Publication types

Meta-Analysis
Systematic Review

MeSH terms

Adult
Airway Extubation / adverse effects
Cannula
Critical Illness / therapy
Humans
Network Meta-Analysis
Noninvasive Ventilation*
Oxygen Inhalation Therapy / methods
Respiratory Insufficiency* / therapy