• Shannon M Fernando, Alexandre Tran, Behnam Sadeghirad, BurnsKaren E AKEADepartment of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.Keenan Research Centre for Biomedical , Eddy Fan, Daniel Brodie, Laveena Munshi, Ewan C Goligher, Deborah J Cook, Robert A Fowler, Margaret S Herridge, Pierre Cardinal, Samir Jaber, MøllerMorten HylanderMHDepartment of Intensive Care, Copenhagen University Righospitalet, Copenhagen, Denmark., Arnaud W Thille, Niall D Ferguson, Arthur S Slutsky, Laurent J Brochard, SeelyAndrew J EAJEDivision of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.Department of Surgery, University of Ottawa, Ottawa, ON, Canada.School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canad, and Bram Rochwerg.
• Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada. sfernando@qmed.ca.
• Intensive Care Med. 2022 Feb 1; 48 (2): 137147137-147.

PurposeSystematic 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.MethodsWe 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.ResultsWe 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.ConclusionsOur 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.© 2021. Springer-Verlag GmbH Germany, part of Springer Nature.

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