Joris Pensier, Arthur Naudet-Lasserre, Clément Monet, Mathieu Capdevila, Yassir Aarab, Inès Lakbar, Gérald Chanques, Nicolas Molinari, Audrey De Jong, Samir Jaber
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Discrepancies were found in the results of recent randomized controlled trials (RCTs) regarding the roles of noninvasive ventilation (NIV), high flow nasal cannula (HFNC) and conventional oxygen therapy (COT) to prevent extubation failure in critically ill patients with obesity.</p><p><strong>Methods: </strong>In this systematic review and network meta-analysis, we searched MEDLINE, Cochrane Center Register of Controlled Trials and Web of Science from 1 January 1998 to 1 July 2024 for RCTs evaluating noninvasive respiratory support therapies (NIV, HFNC, COT, NIV + HFNC) after extubation in critically ill adults with obesity. Primary outcome was reintubation at day 7. Secondary outcome was 28-day mortality. We generated pooled risk ratios (RR) and numbers needed to treat (NNT). We rated risk of bias using the Cochrane risk-of-bias 2.0 tool. The study was registered with PROSPERO (CRD 42022308995).</p><p><strong>Findings: </strong>In seven RCTs including 1933 patients, NIV + HFNC (RR 0.36 [95% confidence interval (CI) 0.16-0.82], NNT = 10 [95% CI 7-33]) and NIV (RR 0.45 [95% CI 0.23-0.88], NNT = 11 [95% CI 8-50]) but not HFNC (RR 0.79 [95% CI 0.40-1.59]) reduced reintubation at day 7, compared to COT. Compared to HFNC, NIV + HFNC (RR 0.46 [95% CI 0.23-0.90], NNT = 14 [95% CI 10-77]) but not NIV (RR 0.57 [95% CI 0.32-1.02]) reduced reintubation at day 7. Compared to HFNC, both NIV (RR 0.31 [95% CI 0.13-0.74], NNT = 15 [95% CI 12-40]) and NIV + HFNC (RR 0.30 [95% CI 0.10-0.89], NNT = 15 [95% CI 11-90]) reduced 28-day mortality.</p><p><strong>Interpretation: </strong>The results suggest that compared to COT and HFNC, NIV alone or with HFNC reduces reintubation in critically ill patients with obesity after extubation. Compared to HFNC, NIV alone or with HFNC reduces mortality. 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引用次数: 0
摘要
背景：肥胖患者是拔管失败的高危人群。最近的随机对照试验（RCTs）发现，无创通气（NIV）、高流量鼻插管（HFNC）和常规氧疗（COT）在预防肥胖症危重患者拔管失败中的作用存在差异。方法：在本系统综述和网络荟萃分析中，我们检索了1998年1月1日至2024年7月1日期间MEDLINE、Cochrane Center Register of Controlled Trials和Web of Science中评估危重症肥胖成人拔管后无创呼吸支持治疗（NIV、HFNC、COT、NIV + HFNC）的随机对照试验。主要结局是第7天再次插管。次要终点为28天死亡率。我们生成了合并风险比（RR）和需要治疗的数字（NNT）。我们使用Cochrane risk-of-bias 2.0工具评定偏倚风险。该研究已在PROSPERO注册（CRD 42022308995）。结果：在包括1933例患者的7项随机对照试验中，与COT相比，NIV + HFNC （RR 0.36[95%可信区间（CI） 0.16-0.82], NNT = 10 [95% CI 7-33]）和NIV （RR 0.45 [95% CI 0.23-0.88], NNT = 11 [95% CI 8-50]）在第7天减少了再插管（RR 0.79 [95% CI 0.40-1.59]）。与HFNC相比，NIV + HFNC （RR 0.46 [95% CI 0.23-0.90], NNT = 14 [95% CI 10-77]）而NIV （RR 0.57 [95% CI 0.32-1.02]）在第7天减少了再插管。与HFNC相比，NIV （RR 0.31 [95% CI 0.13-0.74], NNT = 15 [95% CI 12-40]）和NIV + HFNC （RR 0.30 [95% CI 0.10-0.89], NNT = 15 [95% CI 11-90]）降低了28天死亡率。解释：结果表明，与COT和HFNC相比，单纯使用NIV或联合使用HFNC可减少拔管后肥胖危重患者的再插管。与HFNC相比，NIV单独使用或与HFNC联合使用可降低死亡率。用NIV或NIV + HFNC治疗避免1例死亡的人数为15人。这些发现支持应用NIV减轻重症成人肥胖拔管失败。资金:没有。
Noninvasive respiratory support following extubation in critically ill adults with obesity: a systematic review and network meta-analysis.
Background: Patients with obesity are at high-risk of extubation failure. Discrepancies were found in the results of recent randomized controlled trials (RCTs) regarding the roles of noninvasive ventilation (NIV), high flow nasal cannula (HFNC) and conventional oxygen therapy (COT) to prevent extubation failure in critically ill patients with obesity.
Methods: In this systematic review and network meta-analysis, we searched MEDLINE, Cochrane Center Register of Controlled Trials and Web of Science from 1 January 1998 to 1 July 2024 for RCTs evaluating noninvasive respiratory support therapies (NIV, HFNC, COT, NIV + HFNC) after extubation in critically ill adults with obesity. Primary outcome was reintubation at day 7. Secondary outcome was 28-day mortality. We generated pooled risk ratios (RR) and numbers needed to treat (NNT). We rated risk of bias using the Cochrane risk-of-bias 2.0 tool. The study was registered with PROSPERO (CRD 42022308995).
Findings: In seven RCTs including 1933 patients, NIV + HFNC (RR 0.36 [95% confidence interval (CI) 0.16-0.82], NNT = 10 [95% CI 7-33]) and NIV (RR 0.45 [95% CI 0.23-0.88], NNT = 11 [95% CI 8-50]) but not HFNC (RR 0.79 [95% CI 0.40-1.59]) reduced reintubation at day 7, compared to COT. Compared to HFNC, NIV + HFNC (RR 0.46 [95% CI 0.23-0.90], NNT = 14 [95% CI 10-77]) but not NIV (RR 0.57 [95% CI 0.32-1.02]) reduced reintubation at day 7. Compared to HFNC, both NIV (RR 0.31 [95% CI 0.13-0.74], NNT = 15 [95% CI 12-40]) and NIV + HFNC (RR 0.30 [95% CI 0.10-0.89], NNT = 15 [95% CI 11-90]) reduced 28-day mortality.
Interpretation: The results suggest that compared to COT and HFNC, NIV alone or with HFNC reduces reintubation in critically ill patients with obesity after extubation. Compared to HFNC, NIV alone or with HFNC reduces mortality. The number needed to treat with NIV or NIV + HFNC to avoid one death was 15. These findings support the application of NIV to mitigate extubation failure in critically ill adults with obesity.
期刊介绍：
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