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Abstract
Objectives & Background We aimed to determine the effectiveness of pre-hospital continuous positive airway pressure (CPAP) or bi-level inspiratory positive airway pressure (BiPAP) compared with usual care for adults presenting to the emergency services with acute respiratory failure.
Methods We searched 14 electronic databases and research registers from inception to August 2013. Searches were supplemented by hand-searching the reference list of relevant articles (including citation searching), the World Wide Web and contacting experts in the field. We selected randomised or quasi-randomised controlled trials that compared pre-hospital NIV to a relevant comparator treatment in patients with acute respiratory failure. An aggregate data network meta-analysis was used to jointly estimate intervention effects relative to standard care. A network meta-analysis using a mixture of individual patient-level data (IPD) and aggregate data was carried out to assess potential treatment effect modifiers.
Results The literature searches identified 2284 citations. Eight randomised and two quasi-randomised controlled trials (six CPAP; four BiPAP; sample sizes 23 to 207) were selected for inclusion. The aggregate data network meta-analysis suggested that CPAP was the most effective treatment in terms of mortality (probability=0.989) and intubation rate (probability=0.639), and reduced both mortality (odds ratio 0.41; 95% CrI (credible interval) 0.20 to 0.77) and intubation rate (0.32; 95% CrI 0.17 to 0.62) compared to standard care. The effect of BiPAP upon mortality (odds ratio 1.94; 95% CrI 0.65 to 6.14) and intubation rate (odds ratio 0.40; 95% CrI 0.14 to 1.16) was uncertain. The network meta-analysis using IPD and aggregate data suggested that sex was a modifier of the effect of treatment on mortality.
Conclusion Pre-hospital CPAP can reduce mortality and intubation rates compared to standard care, while the effectiveness of pre-hospital BiPAP is uncertain⇓.
Comparison of mortality for interventions versus standard care from the primary trials
- emergency care systems