Non-invasive ventilation in children and adults in low- and low-middle income countries: A systematic review and meta-analysis

We systematically reviewed the effects of NIV for acute respiratory failure (ARF) in low- and low-middle income countries. We searched MEDLINE, CENTRAL, and EMBASE (to January 2016) for observational studies and trials of NIV for ARF or in the peri-extubation period in adults and post-neonatal children. We abstracted outcomes data and assessed quality. Meta-analyses used random-effect models. Fifty-four studies (ten pediatric/n=1099; 44 adult/n=2904), mostly South Asian, were included. Common diagnoses were pneumonia and chronic obstructive pulmonary disease (COPD). Considering observational studies and the NIV arm of trials, NIV was associated with moderate risks of mortality (pooled risk 9.5%, 95% confidence interval (CI) 4.6–14.5% in children; 16.2% [11.2–21.2%] in adults); NIV failure (10.5% [4.6–16.5%] in children; 28.5% [22.4–34.6%] in adults); and intubation (5.3% [0.8–9.7%] in children; 28.8% [21.9–35.8%] in adults). The risk of mortality was greater (p=0.035) in adults with hypoxemic (25.7% [15.2–36.1%]) vs. hypercapneic (12.8% [7.0–18.6%]) ARF. NIV reduced mortality in COPD (relative risk [RR] 0.47 [0.27–0.79]) and in patients weaning from ventilation (RR 0.48 [0.28–0.80]). The pooled pneumothorax risk was 2.4% (0.8–3.9%) in children and 5.2% (1.0–9.4%) in adults. Meta-analyses had high heterogeneity. NIV for ARF in these settings appears to be effective. •Acute respiratory failure is a common indication for hospital admission in children and adults in low/middle-income countries.•Since access to invasive ventilation is limited, non-invasive ventilation is an attractive alternative in selected patients.•We systematically reviewed the impact of non-invasive ventilation for acute respiratory failure/peri-extubation in this setting.•We found 54 studies, mostly from South Asia.•Non-invasive ventilation was associated with reasonable risks of mortality, endotracheal intubation, and treatment failure.•Non-invasive ventilation seemed safe in children and adults with acute respiratory failure/peri-extubation in these countries.