{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,2]],"date-time":"2026-07-02T22:49:47Z","timestamp":1783032587757,"version":"3.54.6"},"reference-count":127,"publisher":"National Institute for Health and Care Research","issue":"42","license":[{"start":{"date-parts":[[2015,6,1]],"date-time":"2015-06-01T00:00:00Z","timestamp":1433116800000},"content-version":"unspecified","delay-in-days":0,"URL":"http:\/\/www.nationalarchives.gov.uk\/doc\/non-commercial-government-licence\/non-commercial-government-licence.htm"}],"funder":[{"DOI":"10.13039\/501100000664","name":"Health Technology Assessment programme","doi-asserted-by":"publisher","award":["11\/36\/09"],"award-info":[{"award-number":["11\/36\/09"]}],"id":[{"id":"10.13039\/501100000664","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Health Technol Assess"],"abstract":"<jats:sec id=\"abs1-1\"><jats:title>Background<\/jats:title><jats:p>Non-invasive ventilation (NIV), in the form of continuous positive airway pressure (CPAP) or bilevel inspiratory positive airway pressure (BiPAP), is used in hospital to treat patients with acute respiratory failure. Pre-hospital NIV may be more effective than in-hospital NIV but requires additional ambulance service resources.<\/jats:p><\/jats:sec><jats:sec id=\"abs1-2\"><jats:title>Objectives<\/jats:title><jats:p>We aimed to determine the clinical effectiveness and cost-effectiveness of pre-hospital NIV compared with usual care for adults presenting to the emergency services with acute respiratory failure and to identify priorities for future research.<\/jats:p><\/jats:sec><jats:sec id=\"abs1-3\"><jats:title>Data sources<\/jats:title><jats:p>Fourteen electronic databases and research registers (including MEDLINE In-Process &amp; Other Non-Indexed Citations, MEDLINE, EMBASE, and Cumulative Index to Nursing and Allied Health Literature) were searched from inception to August 2013, supplemented by hand-searching reference lists and contacting experts in the field.<\/jats:p><\/jats:sec><jats:sec id=\"abs1-4\"><jats:title>Review methods<\/jats:title><jats:p>We included all randomised or quasi-randomised controlled trials of pre-hospital NIV in patients with acute respiratory failure. Methodological quality was assessed according to established criteria. An aggregate data network meta-analysis (NMA) of mortality and intubation was used to jointly estimate intervention effects relative to usual care. A NMA, using individual patient-level data (IPD) and aggregate data where IPD were not available, was carried out to assess whether or not covariates were treatment effect modifiers. A de novo economic model was developed to explore the costs and health outcomes when pre-hospital NIV (specifically CPAP provided by paramedics) and standard care (in-hospital NIV) were applied to a hypothetical cohort of patients with acute respiratory failure.<\/jats:p><\/jats:sec><jats:sec id=\"abs1-5\"><jats:title>Results<\/jats:title><jats:p>The literature searches identified 2284 citations. Of the 10 studies that met the inclusion criteria, eight were randomised controlled trials and two were quasi-randomised trials (six CPAP; four BiPAP; sample sizes 23\u2013207 participants). IPD were available from seven trials (650 patients). The aggregate data NMA suggested that CPAP was the most effective treatment in terms of mortality (probability\u2009=\u20090.989) and intubation rate (probability\u2009=\u20090.639), and reduced both mortality [odds ratio (OR) 0.41, 95% credible interval (CrI) 0.20 to 0.77] and intubation rate (OR 0.32, 95% CrI 0.17 to 0.62) compared with standard care. The effect of BiPAP on mortality (OR 1.94, 95% CrI 0.65 to 6.14) and intubation rate (OR 0.40, 95% CrI 0.14 to 1.16) compared with standard care was uncertain. The combined IPD and aggregate data NMA suggested that sex was a statistically significant treatment effect modifier for mortality. The economic analysis showed that pre-hospital CPAP was more effective and more expensive than standard care, with an incremental cost-effectiveness ratio of \u00a320,514 per quality-adjusted life-year (QALY) and a 49.5% probability of being cost-effective at the \u00a320,000-per-QALY threshold. Variation in the incidence of eligible patients had a marked impact on cost-effectiveness and the expected value of sample information for a future randomised trial.<\/jats:p><\/jats:sec><jats:sec id=\"abs1-6\"><jats:title>Limitations<\/jats:title><jats:p>The meta-analysis lacked power to detect potentially important differences in outcome (particularly for BiPAP), the intervention was not always compared with the best alternative care (in-hospital NIV) in the primary studies and findings may not be generalisable.<\/jats:p><\/jats:sec><jats:sec id=\"abs1-7\"><jats:title>Conclusions<\/jats:title><jats:p>Pre-hospital CPAP can reduce mortality and intubation rates, but cost-effectiveness is uncertain and the value of further randomised evaluation depends on the incidence of suitable patients. A feasibility study is required to determine if a large pragmatic trial of clinical effectiveness and cost-effectiveness is appropriate.<\/jats:p><\/jats:sec><jats:sec id=\"abs1-8\"><jats:title>Study registration<\/jats:title><jats:p>The study is registered as PROSPERO CRD42012002933.<\/jats:p><\/jats:sec><jats:sec id=\"abs1-9\"><jats:title>Funding<\/jats:title><jats:p>The National Institute for Health Research Health Technology Assessment programme.<\/jats:p><\/jats:sec>","DOI":"10.3310\/hta19420","type":"journal-article","created":{"date-parts":[[2015,7,1]],"date-time":"2015-07-01T11:53:20Z","timestamp":1435751600000},"page":"1-102","update-policy":"https:\/\/doi.org\/10.3310\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":47,"title":["Pre-hospital non-invasive ventilation for acute respiratory failure: a systematic review and cost-effectiveness evaluation"],"prefix":"10.3310","volume":"19","author":[{"given":"Abdullah","family":"Pandor","sequence":"first","affiliation":[{"name":"School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Praveen","family":"Thokala","sequence":"additional","affiliation":[{"name":"School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Steve","family":"Goodacre","sequence":"additional","affiliation":[{"name":"School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Edith","family":"Poku","sequence":"additional","affiliation":[{"name":"School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"John W","family":"Stevens","sequence":"additional","affiliation":[{"name":"School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shijie","family":"Ren","sequence":"additional","affiliation":[{"name":"School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anna","family":"Cantrell","sequence":"additional","affiliation":[{"name":"School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gavin D","family":"Perkins","sequence":"additional","affiliation":[{"name":"Critical Care Medicine, University of Warwick, Coventry, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matt","family":"Ward","sequence":"additional","affiliation":[{"name":"West Midlands Ambulance Service NHS Foundation Trust, West Midlands, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jerry","family":"Penn-Ashman","sequence":"additional","affiliation":[{"name":"West Midlands Ambulance Service NHS Foundation Trust, West Midlands, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"6221","published-online":{"date-parts":[[2015,6]]},"reference":[{"key":"key20150623141328871_ref1-bib1","doi-asserted-by":"publisher","first-page":"192","DOI":"10.1136\/thorax.57.3.192","article-title":"Non-invasive ventilation in acute respiratory failure \u2013 British Thoracic Society standards of care committee","volume":"57","author":"Baudouin","year":"2002","journal-title":"Thorax"},{"key":"key20150623141328871_ref1-bib2","doi-asserted-by":"publisher","first-page":"251","DOI":"10.1093\/ageing\/afn060","article-title":"Acute respiratory failure in the elderly: diagnosis and prognosis","volume":"37","author":"Delmere","year":"2008","journal-title":"Age Ageing"},{"key":"key20150623141328871_ref1-bib3","doi-asserted-by":"publisher","first-page":"238","DOI":"10.1067\/mem.2002.121523","article-title":"Older adults in the emergency department: a systematic review of patterns of use, adverse outcomes, and effectiveness of interventions","volume":"39","author":"Aminzadeh","year":"2002","journal-title":"Ann Emerg Med"},{"key":"key20150623141328871_ref1-bib4","doi-asserted-by":"publisher","first-page":"R82","DOI":"10.1186\/cc4926","article-title":"Acute respiratory failure in the elderly: etiology, emergency diagnosis and prognosis","volume":"10","author":"Ray","year":"2006","journal-title":"Crit Care"},{"key":"key20150623141328871_ref1-bib5","unstructured":"The Health and Social Care Information Centre. 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