Comparative effectiveness of noninvasive ventilation strategies in moderate-to-severe COVID-19: A network meta-analysis of randomized controlled trials

Abstract

Introduction: Noninvasive respiratory support (NIRS) using helmet devices is an emerging treatment for acute respiratory failure in patients with coronavirus disease 2019 (COVID-19). However, the comparative efficacy of helmet NIRS versus other strategies in this context remains elusive.

Methodology: A network meta-analysis was conducted to compare the efficacy of various NIRS strategies in randomized controlled trials (RCTs) involving COVID-19 patients with acute respiratory failure. Strategies assessed included high-flow nasal oxygen (HFNO), continuous positive airway pressure (CPAP), helmet bilevel positive airway pressure (BiPAP), and standard oxygen therapy (SOT). Relevant RCTs were identified via PubMed, Embase, and Cochrane Central Register of Controlled Trials. Outcomes of interest included intubation rate, mortality rate, length of intensive care unit (ICU) stay, and length of hospital stay.

Results: Five RCTs published between 2021 and 2022 were included. Helmet BiPAP was associated with a significantly lower intubation risk compared with HFNO (relative risk (RR): 0.37, 95% confidence interval (CI): 0.16-0.86) and SOT (RR: 0.24, 95% CI: 0.10-0.62). Additionally, helmet BiPAP was linked to shorter ICU stay compared with SOT (RR: 0.10, 95% CI: 0.02-0.67). However, no significant differences were identified in mortality or hospital stay length between SOT, HFNO, CPAP, and helmet BiPAP groups.

Conclusions: Helmet BiPAP is recommended over HFNO and SOT for moderate-to-severe COVID-19 patients with acute respiratory failure, due to its lower intubation risk and shorter ICU stay. No significant differences were noted in mortality or length of hospital stay among the NIRS strategies.