Post-extubation oxygenation strategies in acute respiratory failure: a systematic review and network meta-analysis

Hideto Yasuda, Hiromu Okano, Takuya Mayumi, Chihiro Narita, Yu Onodera, Masaki Nakane, Nobuaki Shime, Hideto Yasuda, Hiromu Okano, Takuya Mayumi, Chihiro Narita, Yu Onodera, Masaki Nakane, Nobuaki Shime

Abstract

Background: High-flow nasal cannula oxygenation (HFNC) and noninvasive positive-pressure ventilation (NPPV) possibly decrease tracheal reintubation rates better than conventional oxygen therapy (COT); however, few large-scale studies have compared HFNC and NPPV. We conducted a network meta-analysis (NMA) to compare the effectiveness of three post-extubation respiratory support devices (HFNC, NPPV, and COT) in reducing the mortality and reintubation risk.

Methods: The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and Ichushi databases were searched. COT, NPPV, and HFNC use were assessed in patients who were aged ≥ 16 years, underwent invasive mechanical ventilation for > 12 h for acute respiratory failure, and were scheduled for extubation after spontaneous breathing trials. The GRADE Working Group Approach was performed using a frequentist-based approach with multivariate random-effect meta-analysis. Short-term mortality and reintubation and post-extubation respiratory failure rates were compared.

Results: After evaluating 4631 records, 15 studies and 2600 patients were included. The main cause of acute hypoxic respiratory failure was pneumonia. Although NPPV/HFNC use did not significantly lower the mortality risk (relative risk [95% confidence interval] 0.75 [0.53-1.06] and 0.92 [0.67-1.27]; low and moderate certainty, respectively), HFNC use significantly lowered the reintubation risk (0.54 [0.32-0.89]; high certainty) compared to COT use. The associations of mortality with NPPV and HFNC use with respect to either outcome did not differ significantly (short-term mortality and reintubation, relative risk [95% confidence interval] 0.81 [0.61-1.08] and 1.02 [0.53-1.97]; moderate and very low certainty, respectively).

Conclusion: NPPV or HFNC use may not reduce the risk of short-term mortality; however, they may reduce the risk of endotracheal reintubation.

Trial registration number and date of registration: PROSPERO (registration number: CRD42020139112, 01/21/2020).

Keywords: Conventional oxygen therapy; High-flow nasal cannula; Meta-analysis; Network meta-analysis; Noninvasive ventilation; Post-extubation; Systematic review.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Network plots correlating noninvasive oxygenation strategies with short-term mortality, reintubation, post-extubation respiratory failure. a Short-term mortality. b. Reintubation, c post-extubation respiratory failure
Fig. 2
Fig. 2
Network meta-analysis forest plots on noninvasive oxygenation strategies and short-term mortality, reintubation, post-extubation respiratory failure. a. Short-term mortality. b. Reintubation. c Post-extubation respiratory failure
Fig. 3
Fig. 3
Surface under cumulative ranking of noninvasive oxygen strategies for short-term mortality, reintubation, post-extubated respiratory failure. a Short-term mortality. b Reintubation. c. Post-extubation respiratory failure

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