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    Original Investigation
    Caring for the Critically Ill Patient
    June 4, 2020

    Association of Noninvasive Oxygenation Strategies With All-Cause Mortality in Adults With Acute Hypoxemic Respiratory Failure: A Systematic Review and Meta-analysis

    Author Affiliations
    • 1Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
    • 2Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
    • 3Department of Medicine, Sinai Health System and University Health Network, Toronto, Ontario, Canada
    • 4Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
    • 5Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada
    • 6Department of Medicine, Division of Critical Care, and Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
    • 7Sidney Liswood Health Science Library, Mount Sinai Hospital, Toronto, Ontario, Canada
    • 8Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
    • 9Applied Health Research Center (AHRC), Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
    • 10Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
    JAMA. Published online June 4, 2020. doi:10.1001/jama.2020.9524
    Key Points

    Question  What are the associations between noninvasive oxygenation strategies and outcomes among adults with acute hypoxemic respiratory failure?

    Findings  In this systematic review and network meta-analysis that included 25 studies and 3804 patients with acute hypoxemic respiratory failure, compared with standard oxygen therapy there was a statistically significant lower risk of death with helmet noninvasive ventilation (risk ratio, 0.40) and face mask noninvasive ventilation (risk ratio, 0.83).

    Meaning  Noninvasive oxygenation strategies compared with standard oxygen therapy were significantly associated with lower risk of death.

    Abstract

    Importance  Treatment with noninvasive oxygenation strategies such as noninvasive ventilation and high-flow nasal oxygen may be more effective than standard oxygen therapy alone in patients with acute hypoxemic respiratory failure.

    Objective  To compare the association of noninvasive oxygenation strategies with mortality and endotracheal intubation in adults with acute hypoxemic respiratory failure.

    Data Sources  The following bibliographic databases were searched from inception until April 2020: MEDLINE, Embase, PubMed, Cochrane Central Register of Controlled Trials, CINAHL, Web of Science, and LILACS. No limits were applied to language, publication year, sex, or race.

    Study Selection  Randomized clinical trials enrolling adult participants with acute hypoxemic respiratory failure comparing high-flow nasal oxygen, face mask noninvasive ventilation, helmet noninvasive ventilation, or standard oxygen therapy.

    Data Extraction and Synthesis  Two reviewers independently extracted individual study data and evaluated studies for risk of bias using the Cochrane Risk of Bias tool. Network meta-analyses using a bayesian framework to derive risk ratios (RRs) and risk differences along with 95% credible intervals (CrIs) were conducted. GRADE methodology was used to rate the certainty in findings.

    Main Outcomes and Measures  The primary outcome was all-cause mortality up to 90 days. A secondary outcome was endotracheal intubation up to 30 days.

    Results  Twenty-five randomized clinical trials (3804 participants) were included. Compared with standard oxygen, treatment with helmet noninvasive ventilation (RR, 0.40 [95% CrI, 0.24-0.63]; absolute risk difference, −0.19 [95% CrI, −0.37 to −0.09]; low certainty) and face mask noninvasive ventilation (RR, 0.83 [95% CrI, 0.68-0.99]; absolute risk difference, −0.06 [95% CrI, −0.15 to −0.01]; moderate certainty) were associated with a lower risk of mortality (21 studies [3370 patients]). Helmet noninvasive ventilation (RR, 0.26 [95% CrI, 0.14-0.46]; absolute risk difference, −0.32 [95% CrI, −0.60 to −0.16]; low certainty), face mask noninvasive ventilation (RR, 0.76 [95% CrI, 0.62-0.90]; absolute risk difference, −0.12 [95% CrI, −0.25 to −0.05]; moderate certainty) and high-flow nasal oxygen (RR, 0.76 [95% CrI, 0.55-0.99]; absolute risk difference, −0.11 [95% CrI, −0.27 to −0.01]; moderate certainty) were associated with lower risk of endotracheal intubation (25 studies [3804 patients]). The risk of bias due to lack of blinding for intubation was deemed high.

    Conclusions and Relevance  In this network meta-analysis of trials of adult patients with acute hypoxemic respiratory failure, treatment with noninvasive oxygenation strategies compared with standard oxygen therapy was associated with lower risk of death. Further research is needed to better understand the relative benefits of each strategy.

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