Use of non-invasive ventilation to wean critically ill adults off invasive ventilation: meta-analysis and systematic review

doi:10.1136/bmj.b1574

Published 21 May 2009, doi:10.1136/bmj.b1574
Cite this as: BMJ 2009;338:b1574

Research

Use of non-invasive ventilation to wean critically ill adults off invasive ventilation: meta-analysis and systematic review

Karen E A Burns, clinical scientist, scientist, assistant professor of medicine¹^,2^,3, Neill K J Adhikari, intensivist, associate scientist, lecturer⁴^,5^,6, Sean P Keenan, head, clinical assistant professor of medicine⁷^,8, Maureen Meade, associate professor of medicine⁹

¹ Interdepartmental Division of Critical Care, St Michael’s Hospital, Toronto, ON, Canada M5B 1W8, ² Keenan Research Centre, Li Ka Shing Knowledge Institute, Toronto, ON, Canada, ³ Divisions of Respiratory and Critical Care Medicine, University of Toronto, Toronto, ON, Canada, ⁴ Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada, ⁵ Sunnybrook Research Institute, Toronto, ON, ⁶ Interdepartmental Division of Critical Care, University of Toronto, Toronto,d ON, ⁷ Department of Critical Care, Royal Columbian Hospital, New Westminster, BC, ⁸ Division of Critical Care Medicine, Department of Medicine, Vancouver, BC, ⁹ Department of Clinical Epidemiology and Biostatics, McMaster University, Hamilton, ON

Correspondence to: K E A Burns Burnsk{at}smh.toronto.on.ca

Objective To summarise the evidence for early extubation withimmediate application of non-invasive ventilation compared withcontinued invasive weaning on important outcomes in intubatedadults with respiratory failure.

Design Systematic review and meta-analysis of randomised andquasi-randomised controlled trials.

Setting Intensive care units.

Participants Critically ill adults receiving invasive ventilation.

Study selection criteria We searched Medline, Embase, and CENTRAL,proceedings from four conferences, and reference lists of relevantstudies to identify relevant trials. Two reviewers independentlyselected trials, assessed trial quality, and abstracted data.

Results We identified 12 trials enrolling 530 participants,mostly with chronic obstructive pulmonary disease. Comparedwith invasive weaning, non-invasive weaning was significantlyassociated with reduced mortality (relative risk 0.55, 95% confidenceinterval 0.38 to 0.79), ventilator associated pneumonia (0.29,95% 0.19 to 0.45), length of stay in intensive care unit (weightedmean 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 weaningtime. Benefits on mortality and weaning failures were non-significantlygreater in trials that exclusively enrolled patients with chronicobstructive pulmonary disease versus mixed populations.

Conclusions Current trials in critically ill adults show a consistentpositive effect of non-invasive weaning on mortality and ventilatorassociated pneumonia, though the net clinical benefits remainto be fully elucidated. Non-invasive ventilation should preferentiallybe used in patients with chronic obstructive pulmonary diseasein a highly monitored environment.

© Burns et al 2009
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Add to CiteULike CiteULike Add to Complore Complore Add to Connotea Connotea Add to Del.icio.us Del.icio.us Add to Digg Digg Add to Reddit Reddit Add to StumbleUpon StumbleUpon Add to Technorati Technorati What's this?

Relevant Articles

Weaning patients off invasive ventilation: Andrew Ferguson
BMJ 2009 338: b728. [Extract] [Full Text]

Measuring inconsistency in meta-analyses: Julian P T Higgins, Simon G Thompson, Jonathan J Deeks, and Douglas G Altman
BMJ 2003 327: 557-560. [Extract] [Full Text] [PDF]