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Cover of Noninvasive Positive-Pressure Ventilation (NPPV) for Acute Respiratory Failure

Noninvasive Positive-Pressure Ventilation (NPPV) for Acute Respiratory Failure

Comparative Effectiveness Reviews, No. 68

Investigators: John W Williams, Jr, MD, MHS, Christopher E Cox, MD, MPH, MHA, C William Hargett, MD, Daniel L Gilstrap, MD, Christian E Castillo, MD, Joseph A Govert, MD, Njira L Lugogo, MD, Remy R Coeytaux, MD, PhD, Douglas C McCrory, MD, MHS, Victor Hasselblad, PhD, Amanda J McBroom, PhD, Rachael Posey, MSLS, Rebecca Gray, DPhil, and Gillian D Sanders, PhD.

Duke Evidence-based Practice Center
Rockville (MD): Agency for Healthcare Research and Quality (US); 2012 Jul.
Report No.: 12-EHC089-EF
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Structured Abstract

Objectives:

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.

Data Sources:

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.

Review Methods:

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.

Results:

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.

Conclusions:

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.

Contents

Acknowledgments: The authors thank Megan von Isenburg, M.L.S., for help with the literature search and retrieval.

Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services1, Contract No. 290-2007-10066-I. Prepared by: Duke Evidence-based Practice Center, Durham, NC

Suggested citation:

Williams JW, Jr., Cox CE, Hargett CW, Gilstrap DL, Castillo CE, Govert JA, Lugogo NL, Coeytaux RR, McCrory DC, Hasselblad V, McBroom AJ, Posey R, Gray R, Sanders GD. Noninvasive Positive-Pressure Ventilation (NPPV) for Acute Respiratory Failure. Comparative Effectiveness Review 68. (Prepared by the Duke Evidence-based Practice Center under Contract No. 290-2007-10066-I.) AHRQ Publication No. 12-EHC089-EF. Rockville, MD: Agency for Healthcare Research and Quality. July 2012. www.effectivehealthcare.ahrq.gov/reports/final.cfm.

This report is based on research conducted by the Duke Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2007-10066-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.

The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.

This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.

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AHRQ (US Agency for Healthcare Research and Quality)

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