Noninvasive ventilation with helmet versus control strategy in patients with acute respiratory failure: a systematic review and meta-analysis of controlled studies

Qi Liu, Yonghua Gao, Rongchang Chen, Zhe Cheng, Qi Liu, Yonghua Gao, Rongchang Chen, Zhe Cheng

Abstract

Background: Noninvasive ventilation (NIV) has proved to be a useful technique for breathing support. However, complications, discomfort, and failure of NIV were commonly caused by the mask. Therefore, the helmet was developed to improve performance and reduce complications; however, there has been no conclusive results on its effect until now. Thus, we performed a systematic review and meta-analysis to investigate the effect of NIV with a helmet versus the control strategy in patients with acute respiratory failure (ARF).

Methods: We searched Cochrane Library, PubMed, Ovid, and Embase databases and bibliographies of relevant articles published before June 2016. Randomized and case-control studies that adopted the helmet as an NIV interface and compared it with another interface were included. The primary outcomes were hospital mortality, intubation rate, and complications. The secondary outcomes included the length of intensive care unit (ICU) stay, gas exchange, and respiratory rate. Pooled odds ratios (ORs) and 95 % confidence intervals (CIs) were calculated by the Mantel-Haenszel method and mean difference by the inverse variance method in a fixed effect model or random effects model according to the heterogeneity.

Results: A total of 11 studies involving 621 patients were included. The overall hospital mortality was 17.53 % in the helmet NIV group versus 30.67 % in the control group. Use of the helmet was associated with lower hospital mortality (OR 0.43, 95 % CI 0.26 to 0.69, p = 0.0005), intubation rate (OR 0.32, 95 % CI 0.21 to 0.47, P < 0.00001), and complications (OR 0.6, 95 % CI 0.4 to 0.92, P = 0.02). In contrast, there was no significant difference in gas exchange and ICU stay (P >0.05). Subgroup analysis found the helmet reduced mortality mainly in hypoxemic ARF patients (P < 0.05) and a lower intubation rate was shown in randomized trials; fewer complications caused by the helmet might be restricted to case-control trials. Additionally, the effect of the helmet on PaCO2 was influenced by type of ARF and ventilation mode (P <0.00001).

Conclusion: NIV with a helmet was associated with reduced hospital mortality and intubation requirement. The helmet was as effective as the mask in gas exchange with no additional advantage. Large randomized controlled trials are needed to provide more robust evidence.

Keywords: Facial mask; Helmet; Noninvasive ventilation.

Figures

Fig. 1
Fig. 1
Flow chart showing the selection of studies in this meta-analysis
Fig. 2
Fig. 2
Effect of NIV with a helmet on primary outcomes and length of ICU stay. The helmet NIV group represents patients receiving NIV with a helmet, the control group represent patients receiving NIV with a mask or oxygen therapy with a mask. Vertical solid line null effect, boxes and horizontal lines outcome in the corresponding study and 95 % CI, filled rhombic boxes overall effect size. a Effect of NIV with a helmet on hospital mortality; b effect of NIV with a helmet on intubation rate; c effect of NIV with a helmet on complications; d effect of NIV with a helmet on length of ICU stay. CI confidence interval, ICU intensive care unit, IV inverse variance method, NIV noninvasive ventilation, M-H Mantel-Haenszel method, SD standard deviation
Fig. 3
Fig. 3
Effect of NIV with a helmet on the gas exchange and respiratory rate. The helmet NIV group represents patients receiving NIV with a helmet, the control group represent patients receiving NIV with mask or oxygen therapy with mask. Vertical solid line null effect, boxes and horizontal lines outcome in the corresponding study and 95 % CI, filled rhombic boxes overall effect size. a Effect of NIV with a helmet on oxygenation; b effect of NIV a with helmet on pH; c effect of NIV with a helmet on PaCO2; d effect of NIV with a helmet on respiratory rate. CI confidence interval, IV inverse variance method, NIV noninvasive ventilation, PaCO2 partial pressure of carbon dioxide in arterial blood, P/F the ratio of partial pressure of oxygenation in arterial blood to fraction of inspired oxygenation, SD standard deviation,
Fig. 4
Fig. 4
Funnel plots to assess publication bias regarding the effect of NIV with a helmet on hospital mortality. SE standard error, OR odds ratio

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