Use of non-invasive ventilation to wean critically ill adults off invasive ventilation: meta-analysis and systematic review.
OBJECTIVE
To summarise the evidence for early extubation with immediate application of non-invasive ventilation compared with continued invasive weaning on important outcomes in intubated adults with respiratory failure.


METHODS
Systematic review and meta-analysis of randomised and quasi-randomised controlled trials.


METHODS
Intensive care units.


METHODS
Critically ill adults receiving invasive ventilation. Study selection criteria We searched Medline, Embase, and CENTRAL, proceedings from four conferences, and reference lists of relevant studies to identify relevant trials. Two reviewers independently selected trials, assessed trial quality, and abstracted data.


RESULTS
We identified 12 trials enrolling 530 participants, mostly with chronic obstructive pulmonary disease. Compared with invasive weaning, non-invasive weaning was significantly associated with reduced mortality (relative risk 0.55, 95% confidence interval 0.38 to 0.79), ventilator associated pneumonia (0.29, 95% 0.19 to 0.45), length of stay in intensive care unit (weighted mean difference -6.27 days, -8.77 to -3.78) and hospital (-7.19 days, -10.80 to -3.58), total duration of ventilation, and duration of invasive ventilation. Non-invasive weaning had no effect on weaning failures or weaning time. Benefits on mortality and weaning failures were non-significantly greater in trials that exclusively enrolled patients with chronic obstructive pulmonary disease versus mixed populations.


CONCLUSIONS
Current trials in critically ill adults show a consistent positive effect of non-invasive weaning on mortality and ventilator associated pneumonia, though the net clinical benefits remain to be fully elucidated. Non-invasive ventilation should preferentially be used in patients with chronic obstructive pulmonary disease in a highly monitored environment.
Burns
Karen E A
KE
Interdepartmental Division of Critical Care, St Michael's Hospital, Toronto, ON, Canada M5B 1W8. Burnsk@smh.toronto.on.ca
Adhikari
Neill K J
NK
Keenan
Sean P
SP
Meade
Maureen
M
D000328:Adult; D016638:Critical Illness / Q000628:therapy*; D006801:Humans; D007902:Length of Stay; D053717:Pneumonia, Ventilator-Associated / Q000517:prevention & control; D029424:Pulmonary Disease, Chronic Obstructive / Q000628:therapy; D016032:Randomized Controlled Trials as Topic; D012131:Respiratory Insufficiency / Q000628:therapy; D012141:Respiratory Tract Infections / Q000628:therapy; D015300:Ventilator Weaning / Q000379:methods / Q000401:mortality