Noninvasive ventilation strategies for patients with severe or critical COVID-19: A rapid review of clinical outcomes
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Abstract
Objectives
To examine whether high flow nasal oxygen (HFNO), continuous positive airway pressure (CPAP), or noninvasive ventilation (NIV) strategies impact mortality, the need for invasive mechanical ventilation (IMV), or hospital and intensive care unit (ICU) length of stay compared to standard oxygen therapy (SOT) or each other in patients with severe or critical COVID-19 with acute hypoxemic respiratory failure.
Methods
A rapid review of randomized controlled trials (RCTs) identified through published systematic and rapid reviews supplemented with a search of bibliographic databases. RCTs were eligible if they compared HFNO, CPAP, or NIV to SOT or another ventilation strategy. Studies were screened, selected, and extracted by a single reviewer and checked by a second reviewer. We assessed risk of bias of included studies using the Cochrane ‘Risk of bias’ tool and used the grading of recommendations, assessment, development, and evaluation (GRADE) approach to judge the certainty of the evidence for mortality, need for IMV, and hospital and ICU length of stay. We sought RCT evidence for non-COVID-19 patients with acute hypoxemic respiratory failure and acute respiratory distress to inform additional comparisons and to supplement the available data for COVID-19.
Results
A total of 5 RCTs comparing ventilation strategies in patients with severe or critical COVID-19 were included. Patient and study characteristics were extracted and evidence and certainty of evidence assessments were completed for comparisons of HFNO and CPAP to standard oxygen therapy and NIV and CPAP to HFNO. An additional 22 RCTs of non-COVID-19 patients were also included and considered.
Results from meta-analysis suggest reductions in mortality and IMV with HFNO ( RR mortality 0 . 87 (0 . 66-1 . 13), IMV 0 . 89 (0 . 77-1 . 03); low quality evidence ) or CPAP ( RR mortality 0 . 87 (0 . 64-1 . 18) low quality evidence, IMV 0 . 81 (0 . 67-0 . 98) moderate quality evidence) compared to SOT. Helmet NIV may reduce IMV ( RR 0 . 69 (0 . 43-1 . 09)) and CPAP may reduce IMV (RR 0 . 69 (0 . 43-1 . 09)) and hospital (1 . 67 days fewer (5 . 43 fewer-2 . 09 more) or ICU length of stay (1 . 02 days fewer (3 . 97 fewer-1 . 93 more)) compared to HFNO (low quality evidence) .
Conclusions
This rapid systematic review highlights the available evidence to support the use of noninvasive ventilation strategies including high flow nasal oxygen, noninvasive ventiltaion (e.g., BiPAP), or CPAP in hospitalized patients with severe or critical COVID-19 and acute hypoxemic respiratory failure who do not need emergent intubation. Findings based on moderate to very low certainty evidence suggest that noninvasive ventilation may be considered as an alternative to standard oxygen therapy to reduce hypoxemia and dyspnea. Additional high quality RCTs are warranted to reduce uncertainty and to fill in important knowledge gaps.
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SciScore for 10.1101/2022.05.25.22275586: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Ethics not detected. Sex as a biological variable not detected. Randomization We aimed to find, assess and synthesize all randomized controlled trials (RCTs) of severe or critical COVID-19 and acute hypoxemic respiratory failure (AHRF). Blinding not detected. Power Analysis not detected. Table 2: Resources
No key resources detected.
Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).
Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:There are several limitations in the included RCTs that should be considered alongside the findings. There was …
SciScore for 10.1101/2022.05.25.22275586: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Ethics not detected. Sex as a biological variable not detected. Randomization We aimed to find, assess and synthesize all randomized controlled trials (RCTs) of severe or critical COVID-19 and acute hypoxemic respiratory failure (AHRF). Blinding not detected. Power Analysis not detected. Table 2: Resources
No key resources detected.
Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).
Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:There are several limitations in the included RCTs that should be considered alongside the findings. There was no evidence located for use of non-invasive ventilation strategies in infants or children or important subpopulations (e.g., pregnant women), very limited evidence to support the specific use of named interfaces for the ventilation strategies considered (e.g., nasal cannula, simple face mask, venturi mask, oronasal, helmet or other), and only one RCT reported patient-important outcomes. The hospital LOS data are challenging to interpret as competing risk for death may not have been appropriately accounted for in most RCTs, or it is not possible to assess how competing risk was handled in an RCT66. In the set of included RCTs, the LOS outcomes are generally either secondary or exploratory outcomes, and as such, the estimates presented may be confounded by death. The LOS data for survivors and non-survivors is rarely presented. Patient heterogeneity was noted by Perkins et al. in the pragmatic RECOVERY-RS RCT but not explored in-depth41. Owing to the rapid synthesis approach, there was no formal extraction or synthesis of harm outcomes. When non-invasive ventilation supports are considered, potential benefits must be consiered alongside any conceivable harms. Use of ventilation strategies could delay other clinical intervention that could lead to worsening patient prognosis, cause discomfort to the patient during use, or result in surficial wounds or pressure sores whe...
Results from TrialIdentifier: We found the following clinical trial numbers in your paper:
Identifier Status Title NCT04326075 Active, not recruiting Early CPAP in COVID-19 Patients With Respiratory Failure. NCT04381923 Withdrawn COVIDNOCHE Trial (HFNO Versus CPAP Helmet) in COVID-19 Pneum… NCT04507802 Not yet recruiting Helmet vs Face Mask in Patients With Acute Respiratory Distr… NCT04667923 Completed Noninvasive Ventilation in Moderate-to-severe COVID-19-assoc… NCT04477668 Recruiting Helmet Non-Invasive Ventilation for COVID-19 Patients NCT04390191 Terminated Early CPAP in COVID-19 Confirmed or Suspected Patients NCT04395807 Terminated Helmet CPAP Versus HFNC in COVID-19 NCT04655638 Completed HFNT vs. COT in COVID-19 Results from Barzooka: We did not find any issues relating to the usage of bar graphs.
Results from JetFighter: We did not find any issues relating to colormaps.
Results from rtransparent:- Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
- Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
- Thank you for including a protocol registration statement.
Results from scite Reference Check: We found no unreliable references.
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