The benefits of non-invasive ventilation for community-acquired pneumonia: a meta-analysis

Abstract

Summary There is an observed international increase in non-invasive ventilation (NIV) application as an alternative to endotracheal intubation (ETI) in non-chronic obsructive pulmonary disease (COPD) patients admitted with community-acquired pneumonia (CAP) despite the lack of strong evidence for its use. The aim of this study is the meta-analysis of data from randomized controlled trials (RCTs) on the effectiveness of NIV vs. standard medical care in adults admitted with severe CAP. Monthly electronic searches on CENTRAL and MEDLINE were performed between September 2017 and October 2019. Only RCTs comparing NIV to standard medical care for the treatment of CAP in adults were eligible for inclusion. The primary outcomes were the rate of ETI and the proportion of patients meeting the criteria of ETI as defined by the investigators. Secondary outcomes were the intensive care unit (ICU) and hospital mortality rate. Study eligibility was independently assessed by two investigators. The risk of bias of included studies was assessed using Cochrane’s Risk of bias Tool. Four RCTs involving a total of 218 participants were eligible for inclusion. Results from the meta-analysis showed that NIV significantly reduced rate of ETI (risk ratio (RR) = 0.46, 95% CI [0.26, 0.79]), the proportion of patients that met the criteria for ETI (RR = 0.28, 95% CI [0.16, 0.49]) and ICU mortality rate (RR = 0.3, 95% CI [0.09, 0.93]). No significant effect on hospital mortality rate was found (RR = 0.44, 95% CI [0.05, 3.67]). The authors rated quality of evidence based on GRADE criteria as ‘Moderate’ for the rate of intubation and proportion of patients meeting ETI criteria outcomes, but quality of evidence for ICU and hospital mortality rate as ‘Low’. This study provides evidence supporting the use of NIV as potential means of avoiding ETI and ICU mortality, in patients with acute respiratory failure due to CAP in the critical care setting. However, there is need for further larger international studies.