Prehospital Noninvasive Ventilation for Acute Respiratory Failure: Systematic Review, Network Meta‐analysis, and Individual Patient Data Meta‐analysis

Abstract

Objectives: This meta-analysis aimed to determine the effectiveness of prehospital continuous positive airway pressure (CPAP) or bilevel inspiratory positive airway pressure (BiPAP) in acute respiratory failure.Methods: Fourteen electronic databases and research registers were searched from inception to August 2013. Randomized or quasi-randomized controlled trials that reported mortality or intubation rate for prehospital CPAP or BiPAP were selected and compared to a relevant comparator in patients with acute respiratory failure. An aggregate data network meta-analysis was used to jointly estimate intervention effects relative to standard care. A network meta-analysis using a mixture of individual patient-level data and aggregate data was carried out to assess potential treatment effect modifiers.Results: Eight randomized and two quasi-randomized controlled trials (six CPAP, four BiPAP, sample sizes 23 to 207) were identified. The aggregate data network meta-analysis suggested that CPAP was the most effective treatment in terms of mortality (probability = 0.989) and intubation rate (probability = 0.639) and reduced both mortality (odds ratio [OR] = 0.41; 95% credible interval [CrI] = 0.20 to 0.77) and intubation rate (OR = 0.32; 95% CrI = 0.17 to 0.62), compared to standard care. The effect of BiPAP on mortality (OR = 1.94; 95% CrI = 0.65 to 6.14) and intubation rate (OR = 0.40; 95% CrI = 0.14 to 1.16) was uncertain. The network meta-analysis using individual patient-level data and aggregate data suggested that sex was a modifier of the effect of treatment on mortality. A cute respiratory failure is a common but lifethreatening medical emergency, especially in elderly patients with respiratory and cardiac diseases. [1][2][3] It is caused by a number of common cardiac or respiratory conditions, including heart failure, pneumonia, and exacerbation of chronic obstructive pulmonary disease. The definitive treatment of acute respiratory failure depends on the underlying cause, but patients often require prehospital treatment. At this point it is difficult to accurately determine the underlying cause, so prehospital treatment of acute respiratory failure often follows a common pathway, rather than being specific to the underlying cause. ConclusionsNoninvasive ventilation (NIV) can be used to treat acute respiratory failure. [4][5][6] It involves providing respiratory support through a tight-fitting mask that is usually applied around the patient's mouth and nose and may take the form of continuous positive airway pressure (CPAP) or bilevel inspiratory positive airway pressure (BiPAP), including noninvasive pressure support ventilation. It is normally used in the hospital, but it may be more effective if treatment is commenced prior to arrival.7 Prehospital NIV is considered in some guidelines, 8,9 but widespread use is limited by the need for additional training and equipment and may be informed by robust evidence of clinical effectiveness and cost-effectiveness.Prehospital NIV has been evaluated in a number o...

CPAP Devices for Emergency Prehospital Use: Looking Inside of It

“…1 We absolutely agree with them that this study only represents a technical basis for clinical studies, which are necessary to make recommendations for clinical use of CPAP devices under different pathophysiological conditions. We also agree that economic aspects are important, but this was beyond the scope of our bench study because the cost of devices may differ depending on the country and agreements between local health authorities RESPIRATORY CARE • MAY 2016 VOL 61 NO 5 719…”

“…1 Although it is considered in guidelines, the need for additional trained health workers, special equipment, and clinical evidence for effectiveness and cost-effectiveness limits widespread use. 1,2 The Boussignac CPAP facial mask is a compact CPAP system that has been used frequently in emergency services. 3,4 This system is simple, safe, and portable and requires only an oxygen source, so it can be used easily by paramedical personnel.…”

Nicht invasive Beatmung

“…spezialisierten Beatmungsein-heiten. Einige Untersuchungen zeigen aber, dass ein früher Einsatz bereits in der Notaufnahme oder sogar präklinisch auf dem Notarztwagen möglich und e ektiv ist [12,13]. Dementsprechend stehen entsprechende Beatmungsgeräte, mit denen eine NIV durchgeführt werden kann, auf vielen Einsatzfahrzeugen bereits zur Verfügung.…”

Non-invasive Ventilation in Adults: A Brief Update

“…NIV has now become an integral tool in the management of both acute and chronic respiratory failure, in both the home setting, emergency room and in the intensive care unit [6][7][8].…”