Noninvasive Ventilation – Saving Lives, Reducing Intubation

July 14, 2020

Written by Aaron Lacy

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When compared to standard oxygen therapy, noninvasive oxygen strategies were associated with a lower risk of death and endotracheal intubation in patients with acute hypoxemic respiratory failure.

Why does this matter?
While sometimes a necessary intervention, endotracheal intubation in acute hypoxemic respiratory failure is associated with severe adverse events. If there are strategies of non-invasive ventilation that can stave off intubation and decrease mortality, these would be of critical importance. 

What’s the point? We are just going to intubate them later…right?
In this systematic review, 3,804 patients from 25 RCTs were analyzed for outcomes between standard oxygenation strategies (flow rates <15 L/min) and non-invasive ventilation (face mask, helmet oxygenation, high-flow nasal cannula). The primary endpoint was all-cause mortality up to 90 days, with secondary outcome of risk of endotracheal intubation up to 30 days.

There was a decrease in 90-day all-cause mortality in patients who had helmet ventilation (RR, 0.40 [95% CI 0.24-0.63]) and face-mask noninvasive ventilation (RR, 0.83 [95% CI, 0.68-0.99]) when compared to standard oxygenation therapy. All forms of noninvasive ventilation; helmet ventilation (RR, 0.26 [95% CI, 0.14-0.46]), face-mask ventilation (RR, 0.76 [95% CI, 0.62-0.90]), and high-flow nasal cannula (RR, 0.76 [95% CI, 0.55-0.99]), were associated with decreased risk of intubation up to 30 days.

I remember several months ago when the COVID-19 pandemic started, and there were rumblings of the possible benefit of ‘early intubation.’ While all the evidence in this review was rated at low to moderate certainty, it suggests we should try to stave off intubation with other means of oxygenation, as it may prevent it and reduce mortality.

Source
Association of Noninvasive Oxygenation Strategies With All-Cause Mortality in Adults With Acute Hypoxemic Respiratory Failure: A Systematic Review and Meta-analysis. JAMA. 2020 Jun 4. doi: 10.1001/jama.2020.9524. [Epub ahead of print]

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