Early non-invasive ventilation for the management of patients with acute respiratory failure: a systematic review and meta-analysis

Background: Non-invasive ventilation (NIV) is a well-established treatment for the management of acute respiratory failure (ARF), particularly in patients with acute exacerbations of chronic obstructive pulmonary disease. Its early application in prehospital and non-intensive care unit (ICU) settings may prevent deterioration and improve several clinical outcomes in patients with ARF due to various causes, but evidence remains inconclusive. Methods: We conducted a systematic review and meta-analysis of randomized and quasi-randomized trials comparing early NIV, defined as its application before or soon after hospital admission (prehospital, emergency department, or general ward initiation), versus standard oxygen therapy in adult patients with ARF. The primary outcome was the need for endotracheal intubation. Secondary outcomes included mortality, ICU admission rate, and hospital length of stay. Results: Thirteen trials including 2172 patients met the inclusion criteria and were included in this analysis. Early NIV significantly reduced intubation rate compared to standard care (56/1085 [5.2%] vs. 113/1047 [10.8%]; relative risk (RR) = 0.49; 95% confidence interval (CI), 0.36–0.66; p < 0.001; I2 = 0%), corresponding to a number needed to treat (NNT) of 18. ICU admissions were also significantly reduced (129/831 [15.5%] vs. 153/798 [19.2%]; RR = 0.78; 95% CI, 0.62–0.97; p = 0.02; I2 = 9%; NNT = 27). No significant differences were observed in mortality (15.0% vs. 17.1%) and hospital length of stay (mean difference = −0.59 days). Conclusions: Early initiation of NIV in patients with ARF in prehospital or non-ICU settings reduces the rate of intubation and ICU admission. These findings support the use of NIV in prehospital and non-ICU settings for the management of ARF. The PROSPERO Registration: CRD420251153734.