Physiological effects of noninvasive respiratory support strategies in adults with acute hypoxemic respiratory failure: a systematic review and network meta-analysis
Bibliographic record
Abstract
In hypoxemic patients, the respective effects of noninvasive respiratory support strategies on lung injury determinants remain unclear, primarily due to the difficulty of obtaining standardized measurements for all interventions within the same study. We conducted a systematic review and network meta-analysis to assess the effects of noninvasive strategies on transpulmonary driving pressure and inspiratory effort in patients with acute hypoxemic respiratory failure. We conducted a systematic search (Ovid MEDLINE, Embase, Scopus, and PubMed) and performed a network meta-analysis of physiological studies involving hypoxemic adults published up to February 16th, 2025. We included studies that assessed inspiratory effort with esophageal manometry under at least two noninvasive respiratory support strategies [standard oxygen, high-flow nasal oxygen (HFNO), noninvasive ventilation (NIV), and continuous positive airway pressure (CPAP)]. Outcomes included transpulmonary driving pressure, inspiratory effort per breath and per minute, respiratory rate, and gas exchange. Treatment effects are displayed as mean differences [95% confidence intervals]. Among 5876 citations, thirteen studies (n = 312 patients) were included (mean PaO 2 /FiO 2 = 131 (± 48) mmHg, mean respiratory rate = 28 (± 8) breaths*min −1 ). Compared to standard oxygen, HFNO and CPAP did not affect transpulmonary driving pressure or effort per breath. HFNO and NIV reduced effort per minute (-95 cmH 2 O*bpm [-140; -49] and -240 cmH 2 O*bpm [-284; -196], respectively), whereas CPAP did not. NIV lowered effort per breath (-5.9 cmH 2 O [-7.4; -4.4]) but increased driving pressure (3.4 cmH₂O [1.4; 5.4]). All strategies reduced respiratory rate, with HFNO producing the greatest decrease (HFNO: -5 breaths*min −1 [-6; -4]; CPAP: -2 breaths*min −1 [-4; -1]; NIV: -4 breaths*min −1 [-5; -2]); all interventions improved PaO 2 /FiO 2 , with CPAP and NIV showing greater effects than HFNO (CPAP: 67 mmHg [55; 80]; NIV: 82 mmHg [56; 108]; HFNO: 24 mmHg [5; 43]). None of the strategies affected PaCO 2 . Noninvasive strategies exert distinct physiological effects: HFNO and NIV reduce effort per minute, while only NIV decreases effort per breath but at the cost of increased driving pressure. CPAP has neutral effects on driving pressure and effort. CPAP and NIV provide greater improvements in oxygenation than HFNO. Individualized selection based on effort levels may help balance the benefits and risks of noninvasive support. CRD42024564035.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.012 | 0.028 |
| Meta-epidemiology (narrow) | 0.002 | 0.001 |
| Meta-epidemiology (broad) | 0.016 | 0.033 |
| Bibliometrics | 0.005 | 0.006 |
| Science and technology studies | 0.001 | 0.001 |
| Scholarly communication | 0.003 | 0.002 |
| Open science | 0.002 | 0.001 |
| Research integrity | 0.002 | 0.002 |
| Insufficient payload (model declined to judge) | 0.003 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".