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Impact of Initial Ventilatory Strategy in Hematological Patients With Acute Respiratory Failure: A Systematic Review and Meta-Analysis*

Amado-Rodríguez, Laura MD, MSc; Bernal, Teresa MD, PhD; López-Alonso, Inés MSc; Blázquez-Prieto, Jorge MSc; García-Prieto, Emilio MD, PhD; Albaiceta, Guillermo M. MD, PhD

doi: 10.1097/CCM.0000000000001613
Review Article
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Objective: Acute respiratory failure in hematological patients is related to a high mortality. Noninvasive mechanical ventilation may benefit a subset of these patients, but the overall effect on mortality and the risks derived from its failure are unclear. Our objective was to review the impact of initial ventilatory strategy on mortality and the risks related to noninvasive mechanical ventilation failure in this group of patients.

Data Sources: Data sources, including PubMed and conference proceedings, were searched from the year 2000 to January 2015.

Study Selection: We selected studies reporting mortality and the need for mechanical ventilation in hematological patients with acute respiratory failure.

Data Extraction: Two trained reviewers independently conducted study selection, abstracted data, and assessed the risk of bias. Discrepancies between reviewers were resolved through discussion and consensus. The outcomes explored were all-cause mortality after mechanical ventilation and incidence of noninvasive mechanical ventilation failure.

Data Synthesis: A random-effects model was used in all the analysis. Thirteen studies, involving 2,380 patients, were included. Use of noninvasive mechanical ventilation was related to a better outcome than initial intubation (risk ratio, 0.74; 95% CI, 0.65–0.84). Failure of noninvasive mechanical ventilation did not increase the overall risk of death (risk ratio, 1.02; 95% CI, 0.93–1.13). There were signs of publication bias and substantial heterogeneity among the studies. Compensation of this bias by using the trim-and-fill method showed a significant risk of death after noninvasive mechanical ventilation failure (risk ratio, 1.07; 95% CI, 1.00–1.14). Meta-regression analysis showed that the predicted risk of death for the noninvasive mechanical ventilation group acted as a significant moderator, with a higher risk of death after noninvasive mechanical ventilation failure in those studies reporting lower predicted mortality.

Conclusions: Noninvasive mechanical ventilation is associated with a lower risk of death in hematological patients with respiratory failure. Noninvasive mechanical ventilation failure may worsen the prognosis, mainly in less severe patients.

Supplemental Digital Content is available in the text.

1Área de Gestión Clínica de Medicina Intensiva, Hospital Valle del Nalón, Langreo, Spain.

2Departamento de Biología Funcional, Instituto Universitario de Oncología del Principado de Asturias, Universidad de Oviedo, Oviedo, Spain.

3Servicio de Hematología, Hospital Universitario Central de Asturias, Oviedo, Spain.

4Departamento de Medicina, Universidad de Oviedo, Oviedo, Spain.

5Servicio de Medicina Intensiva, Hospital Universitario Central de Asturias, Oviedo, Spain.

*See also p. 1444.

Drs. Amado-Rodríguez and Albaiceta had full access to all of the data in the study and take responsibility for the integrity of the data and accuracy of the data analysis. Drs. Amado-Rodríguez and Albaiceta performed the systematic review, study selection, statistical analysis, and elaboration of the article for publication. Dr. Bernal, Dr. López-Alonso, J. Blázquez-Prieto, and Dr. García-Prieto contributed to the data extraction and quality assessment. All the authors participated in the article writing and figure elaboration.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

This study was supported, in part, by Instituto de Salud Carlos III (Acción estratégica en Salud 13/2189, FEDER funds) and Principado de Asturias (GRUPIN14-089).

Dr. Amado-Rodríguez’s institution received funding from Instituto de Salud Carlos III and Fundación para el Fomento en Asturias de la Investigación Científica Aplicada y la Tecnología. Dr. Bernal’s institution received funding from Principado de Asturias (GRUPIN14-089). Dr. López-Alonso’s institution received funding from Instituto de Salud Carlos III, Spain, and Fundación para el Fomento en Asturias de la Investigación Científica Aplicada y la Tecnología (FICYT), Asturias, Spain. Dr. Blázquez-Prieto’s institution received funding from Instituto de Salud Carlos III, Spain, and Fundación para el fomento en Asturias de la investigación citífica aplicada y la tecnología, Asturias, Spain. Dr. Albaiceta’s institution received funding from Instituto de Salud Carlos III (Acción estratégica en Salud 13/2189, FEDER Funds) and Fundación para el Fomento en Asturias de la Investigación Científica Aplicada y la Tecnología (GRUPIN14-089). Dr. Albaiceta is the recipient of a grant from Instituto de Salud Carlos III (INT14-00062). Dr. García-Prieto disclosed that he does not have any potential conflicts of interest.

For information regarding this article, E-mail: Guillermo.muniz@sespa.es

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