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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.
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.
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.
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.
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.