Résumé
Background: patients with obesity are at high-risk of extubation failure. There were discrepancies in the results of recent randomized controlled trials (RCTs) regarding the roles of noninvasive positive pressure ventilation (NIPPV), high flow nasal oxygen (HFNO) and conventional oxygen therapy (COT) to prevent extubation failure in critically ill patients with obesity. Methods: in this systematic review and network meta-analysis, we searched MEDLINE, Cochrane Center Register of Controlled Trials and Web of Science from 1998 to 2023 for RCTs evaluating noninvasive respiratory support therapies (NIPPV, HFNO, COT, NIPPV+HFNO) following extubation in critically ill adults with obesity. Primary outcome was reintubation at day 7. Secondary outcome was 28-day mortality. We generated pooled relative risks (RR) and numbers needed to treat (NNT). We rated the risk of bias using the Cochrane risk-of-bias 2.0 tool. The study was registered with PROSPERO (CRD 42022308995). Findings: in seven RCTs including 1,933 patients, NIPPV+HFNO (RR 0·36 [95% confidence interval (CI) 0·16–0·82], NNT=10 [95% CI 7–33]) and NIPPV (RR 0·45 [95% CI 0·23–0·88], NNT=11 [95% CI 8–50]) but not HFNO (RR 0·79 [95% CI 0·40–1·59]) reduced reintubation at day 7, compared to COT. Compared to HFNO, NIPPV+HFNO (RR 0·46 [95% CI 0·23–0·90], NNT=14 [95% CI 10–77]) but not NIPPV (RR 0·57 [95% CI 0·32–1·02]) reduced reintubation at day 7. Compared to HFNO, both NIPPV (RR 0·31 [95% CI 0·13-0·74], NNT=15 [95% CI 12–40]) and NIPPV+HFNO (RR 0·30 [95% CI 0·10-0·89], NNT=15 [95% CI 11–90]) reduced 28-day mortality. Interpretation: the results suggest that compared to COT and HFNO, NIPPV alone or with HFNO reduces reintubation in critically ill patients with obesity. Compared to HFNO, NIPPV alone or with HFNO reduces mortality. The number needed to treat with NIPPV or NIPPV+HFNO to avoid one death was 15. These findings support the application of NIPPV to mitigate extubation failure in critically ill adults with obesity.