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Association of Noninvasive Oxygenation Strategies With All-Cause Mortality in Adults With Acute Hypoxemic Respiratory FailureA Systematic Review and Meta-analysis

Educational Objective
To understand the associations between noninvasive oxygenation strategies and outcomes among adults with acute hypoxemic respiratory failure
1 Credit CME
Key Points

Question  What are the associations between noninvasive oxygenation strategies and outcomes among adults with acute hypoxemic respiratory failure?

Findings  In this systematic review and network meta-analysis that included 25 studies and 3804 patients with acute hypoxemic respiratory failure, compared with standard oxygen therapy there was a statistically significant lower risk of death with helmet noninvasive ventilation (risk ratio, 0.40) and face mask noninvasive ventilation (risk ratio, 0.83).

Meaning  Noninvasive oxygenation strategies compared with standard oxygen therapy were significantly associated with lower risk of death.

Abstract

Importance  Treatment with noninvasive oxygenation strategies such as noninvasive ventilation and high-flow nasal oxygen may be more effective than standard oxygen therapy alone in patients with acute hypoxemic respiratory failure.

Objective  To compare the association of noninvasive oxygenation strategies with mortality and endotracheal intubation in adults with acute hypoxemic respiratory failure.

Data Sources  The following bibliographic databases were searched from inception until April 2020: MEDLINE, Embase, PubMed, Cochrane Central Register of Controlled Trials, CINAHL, Web of Science, and LILACS. No limits were applied to language, publication year, sex, or race.

Study Selection  Randomized clinical trials enrolling adult participants with acute hypoxemic respiratory failure comparing high-flow nasal oxygen, face mask noninvasive ventilation, helmet noninvasive ventilation, or standard oxygen therapy.

Data Extraction and Synthesis  Two reviewers independently extracted individual study data and evaluated studies for risk of bias using the Cochrane Risk of Bias tool. Network meta-analyses using a bayesian framework to derive risk ratios (RRs) and risk differences along with 95% credible intervals (CrIs) were conducted. GRADE methodology was used to rate the certainty in findings.

Main Outcomes and Measures  The primary outcome was all-cause mortality up to 90 days. A secondary outcome was endotracheal intubation up to 30 days.

Results  Twenty-five randomized clinical trials (3804 participants) were included. Compared with standard oxygen, treatment with helmet noninvasive ventilation (RR, 0.40 [95% CrI, 0.24-0.63]; absolute risk difference, −0.19 [95% CrI, −0.37 to −0.09]; low certainty) and face mask noninvasive ventilation (RR, 0.83 [95% CrI, 0.68-0.99]; absolute risk difference, −0.06 [95% CrI, −0.15 to −0.01]; moderate certainty) were associated with a lower risk of mortality (21 studies [3370 patients]). Helmet noninvasive ventilation (RR, 0.26 [95% CrI, 0.14-0.46]; absolute risk difference, −0.32 [95% CrI, −0.60 to −0.16]; low certainty), face mask noninvasive ventilation (RR, 0.76 [95% CrI, 0.62-0.90]; absolute risk difference, −0.12 [95% CrI, −0.25 to −0.05]; moderate certainty) and high-flow nasal oxygen (RR, 0.76 [95% CrI, 0.55-0.99]; absolute risk difference, −0.11 [95% CrI, −0.27 to −0.01]; moderate certainty) were associated with lower risk of endotracheal intubation (25 studies [3804 patients]). The risk of bias due to lack of blinding for intubation was deemed high.

Conclusions and Relevance  In this network meta-analysis of trials of adult patients with acute hypoxemic respiratory failure, treatment with noninvasive oxygenation strategies compared with standard oxygen therapy was associated with lower risk of death. Further research is needed to better understand the relative benefits of each strategy.

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Article Information

Corresponding Author: Bruno L. Ferreyro, MD, Department of Medicine, Sinai Health System and University Health Network Interdepartmental Division of Critical Care Medicine, University of Toronto, 600 University Ave, Room 18-210, Toronto, ON M5G 1X5, Canada (bruno.ferreyro@uhn.ca).

Accepted for Publication: May 18, 2020.

Published Online: June 4, 2020. doi:10.1001/jama.2020.9524

Author Contributions: Dr Ferreyro had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Ferreyro, Angriman, Munshi, Saskin, da Costa, Scales.

Acquisition, analysis, or interpretation of data: Ferreyro, Angriman, Munshi, del Sorbo, Ferguson, Rochwerg, Ryu, Wunsch, da Costa, Scales.

Drafting of the manuscript: Ferreyro, Angriman, Ryu, da Costa, Scales.

Critical revision of the manuscript for important intellectual content: Ferreyro, Angriman, Munshi, del Sorbo, Ferguson, Rochwerg, Saskin, Wunsch, da Costa, Scales.

Statistical analysis: Ferreyro, Angriman, Rochwerg, Saskin, da Costa.

Administrative, technical, or material support: Ferreyro, Munshi, Ryu.

Supervision: Munshi, Rochwerg, Wunsch, Scales.

Conflict of Interest Disclosures: Dr Ferguson reported receipt of personal fees from Xenios and Getinge. No other disclosures were reported.

Funding/Support: Dr Ferreyro is supported by a Vanier Canada Graduate Scholarship. Dr Angriman is partially supported by research funding from the Department of Critical Care Medicine, Sunnybrook Health Sciences Centre. Dr Rochwerg is supported by a Hamilton Health Sciences Early Career Research Award. Dr Scales holds operating grants from the Canadian Institute for Health Research.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

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