Non-invasive ventilation versus invasive weaning in critically ill adults: a systematic review and meta-analysis

Thorax ◽  
2021 ◽  
pp. thoraxjnl-2021-216993
Author(s):  
Karen E A Burns ◽  
James Stevenson ◽  
Matthew Laird ◽  
Neill K J Adhikari ◽  
Yuchong Li ◽  
...  
Keyword(s):  
Critically Ill ◽  
Total Duration ◽  
Cochrane Central Register ◽  
Invasive Ventilation ◽  
High Quality ◽  
Non Invasive ◽  
Non Invasive Ventilation ◽  
Critically Ill Adults ◽  
Ill Adults ◽  
Duration Of Ventilation

BackgroundExtubation to non-invasive ventilation (NIV) has been investigated as a strategy to wean critically ill adults from invasive ventilation and reduce ventilator-related complications.MethodsWe searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, proceedings of four conferences and bibliographies (to June 2020) for randomised and quasi-randomised trials that compared extubation with immediate application of NIV to continued invasive weaning in intubated adults and reported mortality (primary outcome) or other outcomes. Two reviewers independently screened citations, assessed trial quality and abstracted data.ResultsWe identified 28 trials, of moderate-to-good quality, involving 2066 patients, 44.6% with chronic obstructive pulmonary disease (COPD). Non-invasive weaning significantly reduced mortality (risk ratio (RR) 0.57, 95% CI 0.44 to 0.74; high quality), weaning failures (RR 0.59, 95% CI 0.43 to 0.81; high quality), pneumonia (RR 0.30, 95% CI 0.22 to 0.41; high quality), intensive care unit (ICU) (mean difference (MD) −4.62 days, 95% CI −5.91 to −3.34) and hospital stay (MD −6.29 days, 95% CI −8.90 to −3.68). Non-invasive weaning also significantly reduced the total duration of ventilation, duration of invasive ventilation and duration of ventilation related to weaning (MD −0.57, 95% CI −1.08 to −0.07) and tracheostomy rate. Mortality, pneumonia, reintubation and ICU stay were significantly lower in trials enrolling COPD (vs mixed) populations.ConclusionNon-invasive weaning significantly reduced mortality, pneumonia and the duration of ventilation related to weaning, particularly in patients with COPD. Beneficial effects are less clear (or more careful patient selection is required) in non-COPD patients.PROSPERO registration numberCRD42020201402.

Balanced Crystalloids Versus Saline in Critically Ill Adults: A Systematic Review and Meta-analysis

2019 ◽  
Vol 54 (1) ◽  
pp. 5-13 ◽  
Author(s):  
Drayton A. Hammond ◽  
Simon W. Lam ◽  
Megan A. Rech ◽  
Melanie N. Smith ◽  
Jennifer Westrick ◽  
...  
Keyword(s):  
Critically Ill ◽  
Observational Studies ◽  
Randomized Trials ◽  
Meta Analysis ◽  
Kidney Injury ◽  
Cochrane Central Register ◽  
Central Register ◽  
Critically Ill Adults ◽  
Ill Adults ◽  
Balanced Crystalloids

Background: The optimal resuscitative fluid remains controversial. Objective: To assess the association between crystalloid fluid and outcomes in critically ill adults. Methods: Cumulative Index to Nursing and Allied Health Literature, Scopus, PubMed, and Cochrane Central Register for Controlled Trials were searched from inception through July 2019. Cohort studies and randomized trials of critically ill adults provided predominantly nonperioperative fluid resuscitation with balanced crystalloids or 0.9% sodium chloride (saline) were included. Results: Thirteen studies (n = 30 950) were included. Balanced crystalloids demonstrated lower hospital or 28-/30-day mortality (risk ratio [RR] = 0.86; 95% CI = 0.75-0.99; I2 = 82%) overall, in observational studies (RR = 0.64; 95% CI = 0.41-0.99; I2 = 63%), and approached significance in randomized trials (RR = 0.94; 95% CI = 0.88-1.02; I2 = 0%). New acute kidney injury occurred less frequently with balanced crystalloids (RR = 0.91; 95% CI = 0.85-0.98; I2 = 0%), though progression to renal replacement therapy was similar (RR = 0.91; 95% CI = 0.79-1.04; I2 = 38%). In the sepsis cohort, odds of hospital or 28-/30-day mortality were similar, but the odds of major adverse kidney events occurring in the first 30 days were less with balanced crystalloids than saline (OR = 0.78; 95% CI = 0.66-0.91; I2 = 42%). Conclusion and Relevance: Resuscitation with balanced crystalloids demonstrated lower hospital or 28-/30-day mortality compared with saline in critically ill adults but not specifically those with sepsis. Balanced crystalloids should be provided preferentially to saline in most critically ill adult patients.

scholarly journals Tailored sedation in critically ill COVID-19 patients based on lung damage, and pharmacokinetic and pharmacodynamic profiles

2021 ◽  
Keyword(s):  
Critically Ill ◽  
Positive Airway Pressure ◽  
Deep Sedation ◽  
Lung Damage ◽  
Patient Comfort ◽  
Invasive Ventilation ◽  
Hemodynamic Stability ◽  
Non Invasive ◽  
Non Invasive Ventilation ◽  
Light Sedation

In critically ill COVID-19 patients, proper management of sedation is an important issue. Therefore, for this purpose, several strategies and protocols have been proposed. In this paper, we illustrate an approach focused on lung damage, and both the pharmacokinetic and pharmacodynamic profiles of drugs used. In line with this, during high flow nasal (HFN), continuous positive airway pressure, or non-invasive ventilation, dexmedetomidine-based light sedation can be helpful for maintaining the respiratory driving and improving the patient comfort. A worsening in the respiratory clinical picture with mechanical ventilation may require deep sedation with the use of clonidine. The latter may reduce the hypnotic doses, allowing improved hemodynamic stability. When respiratory performance improves, dexmedetomidine can replace clonidine to reduce the time to extubation.

scholarly journals Nasal versus oronasal masks for home non-invasive ventilation in patients with chronic hypercapnia: a systematic review and individual participant data meta-analysis

Thorax ◽  
2021 ◽  
pp. thoraxjnl-2020-215613
Author(s):  
Marius Lebret ◽  
Antoine Léotard ◽  
Jean Louis Pépin ◽  
Wolfram Windisch ◽  
Emelie Ekkernkamp ◽  
...  
Keyword(s):  
Meta Analysis ◽  
Controlled Trials ◽  
Cochrane Central Register ◽  
Individual Participant Data ◽  
Invasive Ventilation ◽  
Non Invasive ◽  
Non Invasive Ventilation ◽  
Individual Participant ◽  
Randomised Controlled ◽  
Hypoventilation Syndrome

BackgroundThe optimal interface for the delivery of home non-invasive ventilation (NIV) to treat chronic respiratory failure has not yet been determined. The aim of this individual participant data (IPD) meta-analysis was to compare the effect of nasal and oronasal masks on treatment efficacy and adherence in patients with COPD and obesity hypoventilation syndrome (OHS).MethodsWe searched Medline and Cochrane Central Register of Controlled Trials for prospective randomised controlled trials (RCTs) of at least 1 month’s duration, published between January 1994 and April 2019, that assessed NIV efficacy in patients with OHS and COPD. The main outcomes were diurnal PaCO2, PaO2 and NIV adherence (PROSPERO CRD42019132398).FindingsOf 1576 articles identified, 34 RCTs met the inclusion criteria and IPD were obtained for 18. Ten RCTs were excluded because only one type of mask was used, or mask data were missing. Data from 8 RCTs, including 290 IPD, underwent meta-analysis. Oronasal masks were used in 86% of cases. There were no differences between oronasal and nasal masks for PaCO2 (0.61 mm Hg (95% CI −2.15 to 3.38); p=0.68), PaO2 (−0.00 mm Hg (95% CI −4.59 to 4.58); p=1) or NIV adherence (0·29 hour/day (95% CI −0.74 to 1.32); p=0.58). There was no interaction between the underlying pathology and the effect of mask type on any outcome.InterpretationOronasal masks are the most used interface for the delivery of home NIV in patients with OHS and COPD; however, there is no difference in the efficacy or tolerance of oronasal or nasal masks.

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