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The Effect of Non-Invasive Positive Pressure Ventilation (NPPV) via a Face Mask vs. Conventional Mechanical Ventilation (CMV) via Endotracheal Intubation (ETI) in Adult Patients with Acute Respiratory Failure (ARF): A Systematic Review of the Literature

15 August 2009


Background: Traditionally, conventional mechanical ventilation (CMV) and intubation was the preferred route commonly employed by physicians to support patients with acute respiratory failure. However, mechanical ventilation via endotracheal intubation (ETI) may lead to injury of the trachea and may also result in ventilator-associated nosocomial pneumonia. As a consequence, there has been growing interest in NPPV support because of its promising role in avoiding intubation and associated complications.

Purpose: To assess the effectiveness of non-invasive positive pressure ventilation (NPPV) vs. conventional mechanical ventilation (CMV) on the need for intubation, length of hospital ICUs stay, mortality rates, and complications on adult patients with acute respiratory failure (ARF).

Study Design: To select for randomize control trials (RCT), randomized prospective studies, only trials done in the ICU, trials that compare NPPV vs. CMV, articles with a Jadad score of two or greater.

Methods: A multi-method approach was used to identify relevant research for this review. A computerized exhaustive literature search using the following search engines: Medline, Ovid, Cinahl, and Cochrane from the years 1990 to 2009. Bibliographies of all selected articles and review articles that included information on NPPV and CMV were reviewed also. Included were English language studies on adult subjects. Once irrelevant studies had been excluded individual review of the titles and abstracts were conducted. Searches were run numerous times with different combinations of key terms to eliminate irrelevant materials that didn’t address the clinical question and selected PICO.

Results: The three included studies are all randomized studies comparing the effectiveness of NPPV via a face mask vs. CMV via ETI in hospital ICU setting. These three studies are all in agreement on the effect of NPPV reducing the need for intubation with p-values that are statistically significant. Results of hospital ICU length of stay, mortality rates and complications, there exists apparent inconsistencies among the studies, for example, in the study by Honrubia et al and Conti et al, both indicated findings of non-significant differences between NPPV or CMV in hospital length of ICU stay, mortality, and complications. However, in the study by Antonelli et al, the NPPV group had statistically significant findings of decreased length of ICU stay with p=0.002, and fewer complications with p=0.02 respectively.

Conclusion: There is promising evidence in the literature supporting the use of NPPV in adult patients with ARF especially those with acute exacerbation of COPD. At present, with the limited studies published in “randomized controlled trials”, addressing the clinical question, despite promising data from uncontrolled studies, it is clearly necessary to pursue further information in the form of randomized, controlled trials to definitively assess the effectiveness and safety of noninvasive positive pressure ventilation in the setting of acute respiratory failure due to other causes as well.


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