Therapeutics
Review: Noninvasive vs invasive weaning from mechanical ventilation reduces mortality in respiratory failure
Burns KE, Meade MO, Premji A, Adhikari NK. Noninvasive ventilation as a weaning strategy for mechanical ventilation in adults with respiratory failure: a Cochrane systematic review. CMAJ. 2014; 186:E112-22.
Clinical impact ratings: c ★★★★★★✩ p ★★★★★★✩ Question In mechanically ventilated patients with respiratory failure, does noninvasive weaning reduce mortality compared with invasive weaning?
Review scope Included studies compared extubation plus immediate noninvasive ventilation (NIV) with continued invasive weaning in adults with respiratory failure who needed invasive mechanical ventilation for ≥ 24 hours. Exclusion criteria were immediate postoperative settings, NIV after unplanned extubation, and comparison of NIV with unassisted oxygen supplementation. The primary outcome was mortality. Other outcomes included ventilator-associated pneumonia (VAP), weaning failure, intensive care unit (ICU) length of stay, mechanical ventilation duration, and adverse events.
Review methods MEDLINE, EMBASE/Excerpta Medica, and Cochrane Central Register of Controlled Trials, all to May 2013; conference proceedings, Apr 2009 to May 2013; trial registries; and reference lists were searched for randomized controlled trials (RCTs) and quasi-RCTs. Investigators were contacted. 16 trials (n = 994) met the selection criteria: 15 were RCTs, and 1 was a quasi-RCT. 15 trials included patients with chronic obstructive pulmonary disease (COPD): 100% in 9 trials, about 75% in 3 trials, and > 20% in 3 trials. 7 trials used bilevel NIV, 1 used helmet NIV, and 8 used other or several NIV methods. 10 trials compared NIV with invasive pressure support, alone or with other methods; 4 with synchronized intermittent mandatory ventilation, with or without pressure support; and 2 with other methods. 6 trials had low risk for bias in randomization sequence generation, 8 in allocation concealment, and 14 for completeness of data.
Main results Meta-analysis showed that noninvasive weaning reduced mortality, VAP, weaning failure, length of ICU stay, and duration of mechanical ventilation compared with invasive weaning (Table). Noninvasive weaning reduced risk for reintubation (10 trials, n = 789, relative risk reduction [RRR] 35%, 95% CI 3 to 56) and tracheostomy (7 trials, n = 572, RRR 81%, CI 53 to 92)
compared with invasive weaning; groups did not differ for arrhythmia (3 trials, n = 201, RRR 11%, CI −134 to 66).
Conclusion In mechanically ventilated patients with respiratory failure, noninvasive weaning reduces mortality, ventilator-associated pneumonia, and weaning failure compared with invasive weaning. Source of funding: No external funding. For correspondence: Dr. K.E. Burns, University of Toronto, Toronto, ON, Canada. E-mail [email protected]. ■
Commentary Although frequently life-saving, mechanical ventilation can result in such complications as VAP, which prolong length of stay and increase mortality. NIV was initially developed as an alternative to mechanical ventilation and subsequently used to prevent reintubation following extubation. Burns and colleagues updated their earlier review (1) examining NIV as a weaning technique and had similar results: NIV decreased mortality, VAP, and ICU and hospital length of stay. These conclusions are consistent with other recent reviews (2, 3). Glossop and colleagues found benefits of NIV for weaning and decreasing reintubation after extubation (2). The Canadian Critical Care Trials Group examined 146 RCTs and recommended NIV for weaning patients with COPD in experienced centers, in addition to recommending its use in other settings (COPD exacerbation, cardiogenic pulmonary edema, immunocompromised patients, and prevention of reintubation in high-risk patients) (3). Burns and colleagues’ updated review includes new RCTs, increasing the number of patients from about 500 to 1000. Despite the wide range of techniques used for NIV and weaning, benefits remain consistent, supporting widespread adoption of NIV for liberation from mechanical ventilation. However, studies have primarily shown benefit in patients with COPD, where positive end-expiratory pressure may offset the negative consequences of dynamic hyperinflation, so additional studies are needed before NIV can be accepted in other patient groups.
Noninvasive vs invasive weaning in mechanically ventilated adults with respiratory failure* Outcomes
Number of trials (n)
Mortality
16 (994)
Ventilator-associated pneumonia
14 (953)
Weaning failure
8 (605)
Weighted event rates Noninvasive Invasive weaning weaning 12% 7.4% 23%
RRR (95% CI)
NNT (CI)
23%
47% (20 to 64)
10 (7 to 22)
30%
75% (57 to 85)
5 (4 to 6)
36%
37% (4 to 58)
8 (5 to 70)
Mean difference (CI) Length of ICU stay, d Duration of mechanical ventilation, d
13 (907)
−5.6 (−7.9 to −3.3)
7 (385)
−5.6 (−9.5 to −1.8)
*ICU = intensive care unit; other abbreviations defined in Glossary. Weighted event rates, RRR, NNT, and CI calculated from risk ratios and control event rates in article using a random-effects model.
JC8
© 2014 American College of Physicians
Ronald G. Pearl, MD, PhD Stanford University Stanford, California, USA References 1. Burns KE, Adhikari NK, Keenan SP, Meade M. Use of non-invasive ventilation to wean critically ill adults off invasive ventilation: meta-analysis and systematic review. BMJ. 2009;338:b1574. 2. Glossop AJ, Shephard N, Bryden DC, Mills GH. Non-invasive ventilation for weaning, avoiding reintubation after extubation and in the postoperative period: a meta-analysis. Br J Anaesth. 2012;109:305-14. 3. Keenan SP, Sinuff T, Burns KE, et al; Canadian Critical Care Trials Group/Canadian Critical Care Society Noninvasive Ventilation Guidelines Group. Clinical practice guidelines for the use of noninvasive positive-pressure ventilation and noninvasive continuous positive airway pressure in the acute care setting. CMAJ. 2011;183:E195-214.
17 June 2014 | ACP Journal Club | Volume 160 • Number 12
Downloaded From: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/930364/ by a University of California San Diego User on 04/26/2017
Review: Noninvasive vs invasive weaning from mechanical ventilation reduces mortality in respiratory failure
Burns KE, Meade MO, Premji A, Adhikari NK. Noninvasive ventilation as a weaning strategy for mechanical ventilation in adults with respiratory failure: a Cochrane systematic review. CMAJ. 2014; 186:E112-22.
Clinical impact ratings: c ★★★★★★✩ p ★★★★★★✩ Question In mechanically ventilated patients with respiratory failure, does noninvasive weaning reduce mortality compared with invasive weaning?
Review scope Included studies compared extubation plus immediate noninvasive ventilation (NIV) with continued invasive weaning in adults with respiratory failure who needed invasive mechanical ventilation for ≥ 24 hours. Exclusion criteria were immediate postoperative settings, NIV after unplanned extubation, and comparison of NIV with unassisted oxygen supplementation. The primary outcome was mortality. Other outcomes included ventilator-associated pneumonia (VAP), weaning failure, intensive care unit (ICU) length of stay, mechanical ventilation duration, and adverse events.
Review methods MEDLINE, EMBASE/Excerpta Medica, and Cochrane Central Register of Controlled Trials, all to May 2013; conference proceedings, Apr 2009 to May 2013; trial registries; and reference lists were searched for randomized controlled trials (RCTs) and quasi-RCTs. Investigators were contacted. 16 trials (n = 994) met the selection criteria: 15 were RCTs, and 1 was a quasi-RCT. 15 trials included patients with chronic obstructive pulmonary disease (COPD): 100% in 9 trials, about 75% in 3 trials, and > 20% in 3 trials. 7 trials used bilevel NIV, 1 used helmet NIV, and 8 used other or several NIV methods. 10 trials compared NIV with invasive pressure support, alone or with other methods; 4 with synchronized intermittent mandatory ventilation, with or without pressure support; and 2 with other methods. 6 trials had low risk for bias in randomization sequence generation, 8 in allocation concealment, and 14 for completeness of data.
Main results Meta-analysis showed that noninvasive weaning reduced mortality, VAP, weaning failure, length of ICU stay, and duration of mechanical ventilation compared with invasive weaning (Table). Noninvasive weaning reduced risk for reintubation (10 trials, n = 789, relative risk reduction [RRR] 35%, 95% CI 3 to 56) and tracheostomy (7 trials, n = 572, RRR 81%, CI 53 to 92)
compared with invasive weaning; groups did not differ for arrhythmia (3 trials, n = 201, RRR 11%, CI −134 to 66).
Conclusion In mechanically ventilated patients with respiratory failure, noninvasive weaning reduces mortality, ventilator-associated pneumonia, and weaning failure compared with invasive weaning. Source of funding: No external funding. For correspondence: Dr. K.E. Burns, University of Toronto, Toronto, ON, Canada. E-mail [email protected]. ■
Commentary Although frequently life-saving, mechanical ventilation can result in such complications as VAP, which prolong length of stay and increase mortality. NIV was initially developed as an alternative to mechanical ventilation and subsequently used to prevent reintubation following extubation. Burns and colleagues updated their earlier review (1) examining NIV as a weaning technique and had similar results: NIV decreased mortality, VAP, and ICU and hospital length of stay. These conclusions are consistent with other recent reviews (2, 3). Glossop and colleagues found benefits of NIV for weaning and decreasing reintubation after extubation (2). The Canadian Critical Care Trials Group examined 146 RCTs and recommended NIV for weaning patients with COPD in experienced centers, in addition to recommending its use in other settings (COPD exacerbation, cardiogenic pulmonary edema, immunocompromised patients, and prevention of reintubation in high-risk patients) (3). Burns and colleagues’ updated review includes new RCTs, increasing the number of patients from about 500 to 1000. Despite the wide range of techniques used for NIV and weaning, benefits remain consistent, supporting widespread adoption of NIV for liberation from mechanical ventilation. However, studies have primarily shown benefit in patients with COPD, where positive end-expiratory pressure may offset the negative consequences of dynamic hyperinflation, so additional studies are needed before NIV can be accepted in other patient groups.
Noninvasive vs invasive weaning in mechanically ventilated adults with respiratory failure* Outcomes
Number of trials (n)
Mortality
16 (994)
Ventilator-associated pneumonia
14 (953)
Weaning failure
8 (605)
Weighted event rates Noninvasive Invasive weaning weaning 12% 7.4% 23%
RRR (95% CI)
NNT (CI)
23%
47% (20 to 64)
10 (7 to 22)
30%
75% (57 to 85)
5 (4 to 6)
36%
37% (4 to 58)
8 (5 to 70)
Mean difference (CI) Length of ICU stay, d Duration of mechanical ventilation, d
13 (907)
−5.6 (−7.9 to −3.3)
7 (385)
−5.6 (−9.5 to −1.8)
*ICU = intensive care unit; other abbreviations defined in Glossary. Weighted event rates, RRR, NNT, and CI calculated from risk ratios and control event rates in article using a random-effects model.
JC8
© 2014 American College of Physicians
Ronald G. Pearl, MD, PhD Stanford University Stanford, California, USA References 1. Burns KE, Adhikari NK, Keenan SP, Meade M. Use of non-invasive ventilation to wean critically ill adults off invasive ventilation: meta-analysis and systematic review. BMJ. 2009;338:b1574. 2. Glossop AJ, Shephard N, Bryden DC, Mills GH. Non-invasive ventilation for weaning, avoiding reintubation after extubation and in the postoperative period: a meta-analysis. Br J Anaesth. 2012;109:305-14. 3. Keenan SP, Sinuff T, Burns KE, et al; Canadian Critical Care Trials Group/Canadian Critical Care Society Noninvasive Ventilation Guidelines Group. Clinical practice guidelines for the use of noninvasive positive-pressure ventilation and noninvasive continuous positive airway pressure in the acute care setting. CMAJ. 2011;183:E195-214.
17 June 2014 | ACP Journal Club | Volume 160 • Number 12
Downloaded From: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/930364/ by a University of California San Diego User on 04/26/2017
