• Holger J Schünemann, Joanne Khabsa, Karla Solo, Assem M Khamis, Romina Brignardello-Petersen, Amena El-Harakeh, Andrea Darzi, Anisa Hajizadeh, Antonio Bognanni, Anna Bak, Ariel Izcovich, Carlos A Cuello-Garcia, Chen Chen, Ewa Borowiack, Fatimah Chamseddine, Finn Schünemann, Gian Paolo Morgano, Giovanna E U Muti-Schünemann, Guang Chen, Hong Zhao, Ignacio Neumann, Jan Brozek, Joel Schmidt, Layal Hneiny, Leila Harrison, Marge Reinap, Mats Junek, Nancy Santesso, Rayane El-Khoury, Rebecca Thomas, Robby Nieuwlaat, Rosa Stalteri, Sally Yaacoub, Tamara Lotfi, Tejan Baldeh, Thomas Piggott, Yuan Zhang, Zahra Saad, Bram Rochwerg, Dan Perri, Eddy Fan, Florian Stehling, Imad Bou Akl, Mark Loeb, Paul Garner, Stephen Aston, Waleed Alhazzani, Wojciech Szczeklik, Derek K Chu, and Elie A Akl.
• McMaster University, Hamilton, Ontario, Canada (H.J.S., K.S., R.B., A.D., A.H., A.B., C.A.C., F.S., G.P.M., J.B., J.S., L.H., M.J., N.S., R.N., R.S., T.L., T.B., T.P., Y.Z., B.R., D.P., M.L., W.A., D.K.C.).
• Ann. Intern. Med. 2020 Aug 4; 173 (3): 204216204-216.

BackgroundMechanical ventilation is used to treat respiratory failure in coronavirus disease 2019 (COVID-19).PurposeTo review multiple streams of evidence regarding the benefits and harms of ventilation techniques for coronavirus infections, including that causing COVID-19.Data Sources21 standard, World Health Organization-specific and COVID-19-specific databases, without language restrictions, until 1 May 2020.Study SelectionStudies of any design and language comparing different oxygenation approaches in patients with coronavirus infections, including severe acute respiratory syndrome (SARS) or Middle East respiratory syndrome (MERS), or with hypoxemic respiratory failure. Animal, mechanistic, laboratory, and preclinical evidence was gathered regarding aerosol dispersion of coronavirus. Studies evaluating risk for virus transmission to health care workers from aerosol-generating procedures (AGPs) were included.Data ExtractionIndependent and duplicate screening, data abstraction, and risk-of-bias assessment (GRADE for certainty of evidence and AMSTAR 2 for included systematic reviews).Data Synthesis123 studies were eligible (45 on COVID-19, 70 on SARS, 8 on MERS), but only 5 studies (1 on COVID-19, 3 on SARS, 1 on MERS) adjusted for important confounders. A study in hospitalized patients with COVID-19 reported slightly higher mortality with noninvasive ventilation (NIV) than with invasive mechanical ventilation (IMV), but 2 opposing studies, 1 in patients with MERS and 1 in patients with SARS, suggest a reduction in mortality with NIV (very-low-certainty evidence). Two studies in patients with SARS report a reduction in mortality with NIV compared with no mechanical ventilation (low-certainty evidence). Two systematic reviews suggest a large reduction in mortality with NIV compared with conventional oxygen therapy. Other included studies suggest increased odds of transmission from AGPs.LimitationDirect studies in COVID-19 are limited and poorly reported.ConclusionIndirect and low-certainty evidence suggests that use of NIV, similar to IMV, probably reduces mortality but may increase the risk for transmission of COVID-19 to health care workers.Primary Funding SourceWorld Health Organization. (PROSPERO: CRD42020178187).

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