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Noninvasive Positive-Pressure Ventilation (NPPV) for Acute Respiratory Failure
Comparative Effectiveness Reviews, No. 68
Investigators: John W Williams, Jr, MD, MHS, Christopher E Cox, MD, MPH, MHA, C William Hargett, MD, Daniel L Gilstrap, MD, Christian E Castillo, MD, Joseph A Govert, MD, Njira L Lugogo, MD, Remy R Coeytaux, MD, PhD, Douglas C McCrory, MD, MHS, Victor Hasselblad, PhD, Amanda J McBroom, PhD, Rachael Posey, MSLS, Rebecca Gray, DPhil, and Gillian D Sanders, PhD.
Author Information and AffiliationsStructured Abstract
Objectives:
Noninvasive positive-pressure ventilation (NPPV) is a form of mechanical ventilatory support delivered to patients with acute respiratory failure through a noninvasive interface. In patients with a range of etiologies for acute respiratory failure, NPPV has the potential to reduce complications and improve outcomes compared to invasive ventilation.
Data Sources:
We searched PubMed®, Embase®, and the Cochrane Database of Systematic Reviews for English-language studies published since 1990 that compared NPPV versus supportive care or invasive ventilation, bilevel positive airway pressure (BPAP) versus continuous positive airway pressure (CPAP), NPPV versus conventional weaning from invasive ventilation, or NPPV versus supportive care to prevent or treat acute respiratory failure postextubation.
Review Methods:
Two investigators screened each abstract and full-text article for inclusion, abstracted data, and performed quality ratings, efficacy-effectiveness ratings, and evidence grading. Random-effects models were used to compute summary estimates of effect.
Results:
Forty-four studies (4,122 subjects) compared NPPV to supportive care, 5 (405 subjects) compared NPPV to invasive ventilation, 12 (1,520 subjects) compared BPAP to CPAP, and 12 (1,463 subjects) evaluated NPPV for weaning or in patients postextubation. Most studies were conducted in patients with acute respiratory failure due to congestive heart failure or severe exacerbations of chronic obstructive pulmonary disease (COPD). BPAP was the most common NPPV modality.
Compared with supportive care, NPPV reduced hospital mortality (odds ratio [OR] 0.56; 95% confidence interval [CI], 0.44 to 0.72), intubation rates (OR 0.31; 0.23 to 0.41), and hospital-acquired pneumonia. Outcomes did not differ for the major NPPV modalities. Compared with conventional weaning from invasive ventilation, NPPV was associated with a lower hospital mortality (OR 0.17; 0.05 to 0.65) and decreased rates of hospital-acquired pneumonia (OR 0.14; 0.04 to 0.48) in patients with COPD. When used to prevent recurrent respiratory failure postextubation, NPPV decreased mortality (OR 0.60; 0.34 to 1.04) and reintubation (OR 0.43; 0.24 to 0.77) only in those at high risk.
Effects on mortality were smaller for studies with more characteristics of effectiveness trials, but did not differ for intubation rates. Effects did not differ by clinical setting or global geographical region.
Conclusions:
For patients with acute respiratory failure due to severe exacerbations of COPD or congestive heart failure, NPPV improves outcomes compared to supportive care alone. Current evidence suggests potential benefit for patients with acute respiratory failure who are postoperative or post-transplant, and in selected populations, as a method to facilitate weaning from invasive ventilation or prevent recurrent respiratory failure postextubation. Limited evidence shows similar treatment effects across different settings and the possibility of less benefit in trials designed to replicate usual clinical practice.
Contents
- Preface
- Key Informants
- Technical Expert Panel
- Peer Reviewers
- Executive Summary
- Introduction
- Methods
- Results
- Discussion
- References
- Abbreviations and Acronyms
- Appendix A Exact Search Strings
- Appendix B Efficacy-Effectiveness Rating Form
- Appendix C Data Abstraction Elements
- Appendix D Analyses of Potential Publication Bias
- Appendix E Included Studies
- Appendix F Excluded Studies
- Appendix G Characteristics of Included Studies
Acknowledgments: The authors thank Megan von Isenburg, M.L.S., for help with the literature search and retrieval.
Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services1, Contract No. 290-2007-10066-I. Prepared by: Duke Evidence-based Practice Center, Durham, NC
Suggested citation:
Williams JW, Jr., Cox CE, Hargett CW, Gilstrap DL, Castillo CE, Govert JA, Lugogo NL, Coeytaux RR, McCrory DC, Hasselblad V, McBroom AJ, Posey R, Gray R, Sanders GD. Noninvasive Positive-Pressure Ventilation (NPPV) for Acute Respiratory Failure. Comparative Effectiveness Review 68. (Prepared by the Duke Evidence-based Practice Center under Contract No. 290-2007-10066-I.) AHRQ Publication No. 12-EHC089-EF. Rockville, MD: Agency for Healthcare Research and Quality. July 2012. www.effectivehealthcare.ahrq.gov/reports/final.cfm.
This report is based on research conducted by the Duke Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2007-10066-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.
This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.
None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.
- 1
540 Gaither Road, Rockville, MD 20850; www
.ahrq.gov
- Review Noninvasive positive-pressure ventilation as a weaning strategy for intubated adults with respiratory failure.[Cochrane Database Syst Rev. 2013]Review Noninvasive positive-pressure ventilation as a weaning strategy for intubated adults with respiratory failure.Burns KE, Meade MO, Premji A, Adhikari NK. Cochrane Database Syst Rev. 2013 Dec 9; 2013(12):CD004127. Epub 2013 Dec 9.
- Review Noninvasive positive pressure ventilation for acute respiratory failure following upper abdominal surgery.[Cochrane Database Syst Rev. 2015]Review Noninvasive positive pressure ventilation for acute respiratory failure following upper abdominal surgery.Faria DA, da Silva EM, Atallah ÁN, Vital FM. Cochrane Database Syst Rev. 2015 Oct 5; 2015(10):CD009134. Epub 2015 Oct 5.
- Review Role of noninvasive positive-pressure ventilation in postextubation respiratory failure: a meta-analysis.[Respir Care. 2007]Review Role of noninvasive positive-pressure ventilation in postextubation respiratory failure: a meta-analysis.Agarwal R, Aggarwal AN, Gupta D, Jindal SK. Respir Care. 2007 Nov; 52(11):1472-9.
- Review Noninvasive positive pressure ventilation as a weaning strategy for intubated adults with respiratory failure.[Cochrane Database Syst Rev. 2003]Review Noninvasive positive pressure ventilation as a weaning strategy for intubated adults with respiratory failure.Burns KE, Adhikari NK, Meade MO. Cochrane Database Syst Rev. 2003; (4):CD004127.
- Review Noninvasive positive pressure ventilation as a weaning strategy for intubated adults with respiratory failure.[Cochrane Database Syst Rev. 2010]Review Noninvasive positive pressure ventilation as a weaning strategy for intubated adults with respiratory failure.Burns KE, Adhikari NK, Keenan SP, Meade MO. Cochrane Database Syst Rev. 2010 Aug 4; (8):CD004127. Epub 2010 Aug 4.
- Noninvasive Positive-Pressure Ventilation (NPPV) for Acute Respiratory FailureNoninvasive Positive-Pressure Ventilation (NPPV) for Acute Respiratory Failure
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