Update Alert 2: Ventilation Techniques and Risk for Transmission of Coronavirus Disease, Including COVID-19
Authors: Rebecca Thomas, Tamara Lotfi, Gian Paolo Morgano, Andrea Darzi, Marge Reinap
Journal: Annals of Internal Medicine (2020)

Letters13 October 2020Update Alert 2: Ventilation Techniques and Risk for Transmission of Coronavirus Disease, Including COVID-19FREERebecca Thomas, MPH, MBChB, Tamara Lotfi, MD, MPH, Gian Paolo Morgano, MSc, Andrea Darzi, MD, MPH, and Marge Reinap, MA, and COVID-19 Systematic Urgent Review Group Effort (SURGE) Study AuthorsRebecca Thomas, MPH, MBChBLiverpool School of Tropical Medicine, Liverpool, United Kingdom (R.T.), Tamara Lotfi, MD, MPHMcMaster University, Hamilton, Ontario, Canada (T.L., G.P.M., A.D.), Gian Paolo Morgano, MScMcMaster University, Hamilton, Ontario, Canada (T.L., G.P.M., A.D.), Andrea Darzi, MD, MPHMcMaster University, Hamilton, Ontario, Canada (T.L., G.P.M., A.D.), and Marge Reinap, MALondon School of Hygiene and Tropical Medicine, London United Kingdom (M.R.), and COVID-19 Systematic Urgent Review Group Effort (SURGE) Study AuthorsAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/L20-1211 SectionsSupplemental MaterialAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail We have updated the protocol of our living systematic review (PROSPERO: CRD42020178187). This most recent search update, which was done on 11 July 2020, identified 2756 citations. Of these, we included 3 observational cohort studies of patients with coronavirus disease 2019 (COVID-19) in the updated quantitative synthesis (1–3). One of the new studies compared bilevel positive airway pressure (BiPAP) with continuous positive airway pressure (CPAP) (1), 1 compared high-flow oxygen by nasal cannula (HFNC) with invasive mechanical ventilation (IMV) (2), and the last compared noninvasive ventilation (NIV) with IMV (3) (Supplement Table 1).The first study compared BiPAP with CPAP in frail patients with COVID-19 who were deemed unsuitable for IMV by the treating team (1). We judged this study to have high risk of bias, with a Newcastle-Ottawa Scale score of 5. In the initial systematic review and the first update, we did not find any studies examining the comparative efficacy of CPAP or BiPAP in patients with COVID-19 (4, 5). This new study found a mortality rate of 40% in patients receiving BiPAP and 52% in those receiving CPAP; however, the sample was small (n = 28; 5 received BiPAP and 23 received CPAP), contributing to imprecision and limiting conclusions.The second study compared HFNC with IMV in patients with COVID-19 in the intensive care unit (2). We judged this study to have high risk of bias, with a Newcastle-Ottawa Scale score of 3. We previously included 2 studies that gave imprecise estimates of the comparative efficacy of HFNC or IMV on mortality in COVID-19 (6, 7). The mortality rate in the new study was 14% in patients receiving HFNC and 100% in those receiving IMV, although the sample was small (n = 13; 7 received HFNC and 6 received IMV), limiting our ability to generate conclusions (Supplement Table 2).The final study compared NIV with IMV in critically ill patients with COVID-19. This study was judged to have low risk of bias, with a Newcastle-Ottawa Scale score of 8 (3). The results suggested a lower mortality rate in those receiving NIV (odds ratio, 0.34 [95% CI, 0.16 to 0.71]). We compared this study with another found as part of our initial search (7). This demonstrated an inconsistent effect on mortality (hazard ratio, 0.75 [CI, 0.16 to 3.45]). This other study suggested higher mortality in those treated with NIV (hazard ratio, 1.61 [CI, 0.84 to 3.09]) (very low certainty of evidence due to the nonrandomized study designs, imprecision, and inconsistency). In the prior searches, we identified 4 other cohort studies examining this effect (8–11). Including the new data, the results are imprecise and inconsistent when examining the effect of NIV versus IMV (Supplement Figure and Supplement Table 2).In summary, the results suggest no change in the findings of the original systematic review. Noninvasive ventilation may have similar effects to IMV on mortality, but the evidence is uncertain (Supplement Table 2).References1. Burns GP, Lane ND, Tedd HM, et al. Improved survival following ward-based non-invasive pressure support for severe hypoxia in a cohort of frail patients with COVID-19: retrospective analysis from a UK teaching hospital. BMJ Open Respir Res. 2020;7. [PMID: 32624494] doi:10.1136/bmjresp-2020-000621 CrossrefMedlineGoogle Scholar2. Lalla U, Allwood BW, Louw EH, et al. The utility of high-flow nasal cannula oxygen therapy in the management of respiratory failure secondary to COVID-19 pneumonia [Letter]. S Afr Med J. 2020;110:12941. [PMID: 32880537] MedlineGoogle Scholar3. Wang T, Tang C, Chen R, et al. Clinical features of coronavirus disease 2019 patients with mechanical ventilation: a nationwide study in China. Crit Care Med. 2020;48:e809-e812. [PMID: 32618693] doi:10.1097/CCM.0000000000004473 CrossrefMedlineGoogle Scholar4. Schünemann HJ, Khabsa J, Solo K, et al. Ventilation techniques and risk for transmission of coronavirus disease, including COVID-19: a living systematic review of multiple streams of evidence. Ann Intern Med. 2020;173:204-216. doi:10.7326/M20-2306 LinkGoogle Scholar5. Rochwerg B, Solo K, Darzi A, et al. Update alert: ventilation techniques and risk for transmission of coronavirus disease, including COVID-19 [Letter]. Ann Intern Med. 2020;173:W122. doi:10.7326/L20-0944 LinkGoogle Scholar6. Hong Y, Li J, Zhao G, et al. Clinical diagnosis and prognosis analysis of severe patients with novel coronavirus pneumonia. Ningxia Med J. 2020;42:337-339. Google Scholar7. Wang K, Zhang Z, Yu M, et al. 15-day mortality and associated risk factors for hospitalized patients with COVID-19 in Wuhan, China: an ambispective observational cohort study [Letter]. Intensive Care Med. 2020;46:1472-1474. [PMID: 32328724] doi:10.1007/s00134-020-06047-w CrossrefMedlineGoogle Scholar8. Duca A, Memaj I, Zanardi F, et al. Severity of respiratory failure and outcome of patients needing a ventilatory support in the emergency department during Italian novel coronavirus SARS-CoV2 outbreak: preliminary data on the role of helmet CPAP and non-invasive positive pressure ventilation. EClinicalMedicine. 2020;24:100419. [PMID: 32766538] doi:10.1016/j.eclinm.2020.100419 CrossrefMedlineGoogle Scholar9. Wu C, Chen X, Cai Y, et al. Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan, China. JAMA Intern Med. 2020;180:934-943. [PMID: 32167524] doi:10.1001/jamainternmed.2020.0994 CrossrefMedlineGoogle Scholar10. Zheng Y, Sun LJ, Xu M, et al. Clinical characteristics of 34 COVID-19 patients admitted to intensive care unit in Hangzhou, China. J Zhejiang Univ Sci B. 2020;21:378-387. [PMID: 32425003] doi:10.1631/jzus.B2000174 CrossrefMedlineGoogle Scholar11. Shang J, Du R, Lu Q, et al. The treatment and outcomes of patients with Covid-19 in Hubei, China: a multicentered, retrospective, observational study. SSRN. Preprint posted online 3 March 2020. doi:10.2139/ssrn.3546060 Google Scholar Comments 0 Comments Sign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: Rebecca Thomas, MPH, MBChB; Tamara Lotfi, MD, MPH; Gian Paolo Morgano, MSc; Andrea Darzi, MD, MPH; Marge Reinap, MAAffiliations: Liverpool School of Tropical Medicine, Liverpool, United Kingdom (R.T.)McMaster University, Hamilton, Ontario, Canada (T.L., G.P.M., A.D.)London School of Hygiene and Tropical Medicine, London United Kingdom (M.R.)Disclaimer: The systematic review was commissioned and in part paid for by the World Health Organization. The authors alone are responsible for the views expressed in this article, and they do not necessarily represent the decisions, policy, or views of the World Health Organization.Financial Support: By the World Health Organization.Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=L20-1211.Corresponding Authors: Holger J. Schünemann, MD, PhD, MSc, Michael G. DeGroote Cochrane Canada and McMaster GRADE Centres, McMaster University, HSC-2C, 1280 Main Street West, Hamilton, ON L8N 3Z5, Canada (e-mail, schuneh@mcmaster.ca), and Elie A. Akl, MD, MPH, PhD, Clinical Research Institute and AUB GRADE Center, American University of Beirut, PO Box 11-0236/CRI (E15), Riad-El-Solh Beirut, 1107 2020 Beirut, Lebanon (e-mail, ea32@aub.edu.lb).This article was published at Annals.org on 13 October 2020.* SURGE Study Authors include Bram Rochwerg, MD, MSc; Elie A. Akl, MD, MPH, PhD; Giovanna E.U. Muti-Schünemann, Cand. Med; Joanne Khabsa, MPH; Karla Solo, MSc; Anna Bak, PharmD; Finn Schünemann, MD; Antonio Bognanni, MD; Leila Harrison, MPH; Rosa Stalteri, BSHc; Anisa Hajizadeh, MPH; Ewa Borowiack, MSc; Assem M. Khamis, MD; Guang Chen, MD, PhD; Hong Zhao, PhD; Chen Chen, MM; Layal Hneiny, MPH, MLIS; Holger J. Schünemann, MD, PhD, MSc PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoVentilation Techniques and Risk for Transmission of Coronavirus Disease, Including COVID-19 Holger J. Schünemann , Joanne Khabsa , Karla Solo , Assem M. Khamis , Romina Brignardello-Petersen , Amena El-Harakeh , Andrea Darzi , Anisa Hajizadeh , Antonio Bognanni , Anna Bak , Ariel Izcovich , Carlos A. Cuello-Garcia , Chen Chen , Ewa Borowiack , Fatimah Chamseddine , Finn Schünemann , Gian Paolo Morgano , Giovanna E.U. Muti-Schünemann , Guang Chen , Hong Zhao , Ignacio Neumann , Jan Brozek , Joel Schmidt , Layal Hneiny , Leila Harrison , Marge Reinap , Mats Junek , Nancy Santesso , Rayane El-Khoury , Rebecca Thomas , Robby Nieuwlaat , Rosa Stalteri , Sally Yaacoub , Tamara Lotfi , Tejan Baldeh , Thomas Piggott , Yuan Zhang , Zahra Saad , Bram Rochwerg , Dan Perri , Eddy Fan , Florian Stehling , Imad Bou Akl , Mark Loeb , Paul Garner , Stephen Aston , Waleed Alhazzani , Wojciech Szczeklik , Derek K. Chu , and Elie A. Akl Update Alert: Ventilation Techniques and Risk for Transmission of Coronavirus Disease, Including COVID-19 Bram Rochwerg , Karla Solo , Andrea Darzi , Guang Chen , and Assem M. Khamis , and COVID-19 Systematic Urgent Review Group Effort (SURGE) Study Authors* Update Alert 3: Ventilation Techniques and Risk for Transmission of Coronavirus Disease, Including COVID-19 Giovanna Elsa Ute Muti-Schüenemann , Wojciech Szczeklik , Karla Solo , Joanne Khabsa , Rebecca Thomas , Ewa Borowiack , Assem M. Khamis , Layal Hneiny , Andrea Darzi , Leila Harrison , Anna Bak , Antonio Bongnanni , Gian Paolo Morgano , Rosa Stalteri , Anisa Hajizadeh , Tamara Lotfi , Marge Reinap , Bram Rochwerg , Elie A. Akl , Holger J. Schünemann Metrics Cited byThe optimal management of the patient with COVID‐19 pneumonia: HFNC, NIV/CPAP or mechanical ventilation? 1 December 2020Volume 173, Issue 11 Page: W152-W153 Keywords Continuous positive airway pressure COVID-19 Death rates Global health Grading of Recommendations Assessment Development and Evaluation Hazard ratio Intermittant mandatory ventilation Mortality Noninvasive ventilation Systematic reviews ePublished: 13 October 2020 Issue Published: 1 December 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...