by Xiaoyang Zhou, Shengmi Yao, Pingping Dong, Bixin Chen,
Zhaojun Xu and Hua Wang
Critical Care volume 24,
Article number: 370 (2020)
Background
Respiratory support has been increasingly used after
extubation for the prevention of re-intubation and improvement of prognosis in
critically ill medical patients. However, the optimal respiratory support
method is still under debate. This network meta-analysis (NMA) aims to evaluate
the comparative effectiveness of various respiratory support methods used for
preventive purposes after scheduled extubation in critically ill medical
patients.
Methods
A systematic database search was performed from inception to
December 19, 2019, for randomized controlled trials (RCTs) that compared a
preventive use of different respiratory support methods, including conventional
oxygen therapy (COT), noninvasive ventilation (NIV), high-flow oxygen therapy
(HFOT), and combinational use of HFOT and NIV (HFOT+NIV), after planned
extubation in adult critically ill medical patients. Study selection, data
extraction, and quality assessments were performed in duplicate. The primary
outcomes included re-intubation rate and short-term mortality.
Results
Seventeen RCTs comprising 3341 participants with 4
comparisons were included. Compared with COT, NIV significantly reduced the
re-intubation rate [risk ratio (RR) 0.55, 95% confidence interval (CI) 0.39 to
0.77; moderate quality of evidence] and short-term mortality (RR 0.66, 95% CI
0.48 to 0.91; moderate quality of evidence). Compared to COT, HFOT had a
beneficial effect on the re-intubation rate (RR 0.55, 95% CI 0.35 to 0.86; moderate
quality of evidence) but no effect on short-term mortality (RR 0.79, 95% CI
0.56 to 1.12; low quality of evidence). No significant difference in the
re-intubation rate or short-term mortality was found among NIV, HFOT, and
HFOT+NIV. The treatment rankings based on the surface under the cumulative
ranking curve (SUCRA) from best to worst for re-intubation rate were HFOT+NIV
(95.1%), NIV (53.4%), HFOT (51.2%), and COT (0.3%), and the rankings for
short-term mortality were NIV (91.0%), HFOT (54.3%), HFOT+NIV (43.7%), and COT
(11.1%). Sensitivity analyses of trials with a high risk of extubation failure
for the primary outcomes indicated that the SUCRA rankings were comparable to
those of the primary analysis.
Conclusions
After scheduled extubation, the preventive use of NIV is
probably the most effective respiratory support method for comprehensively
preventing re-intubation and short-term death in critically ill medical
patients, especially those with a high risk of extubation failure.
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