High-flow nasal cannula oxygen therapy is superior to conventional oxygen therapy but not to noninvasive mechanical ventilation on intubation rate: a systematic review and meta-analysis

Abstract

Background: High-flow nasal cannula oxygen (HFNC) is a relatively new therapy used in adults with respiratory failure. Whether it is superior to conventional oxygen therapy (COT) or to noninvasive mechanical ventilation (NIV) remains unclear. The aim of the present study was to investigate whether HFNC was superior to either COT or NIV in adult acute respiratory failure patients.

Methods: A review of the literature was conducted from the electronic databases from inception up to 20 October 2016. Only randomized clinical trials comparing HFNC with COT or HFNC with NIV were included. The intubation rate was the primary outcome; secondary outcomes included the mechanical ventilation rate, the rate of escalation of respiratory support and mortality.

Results: Eleven studies that enrolled 3459 patients (HFNC, n = 1681) were included. There were eight studies comparing HFNC with COT, two comparing HFNC with NIV, and one comparing all three. HFNC was associated with a significant reduction in intubation rate (OR 0.52, 95% CI 0.34 to 0.79, P = 0.002), mechanical ventilation rate (OR 0.56, 95% CI 0.33 to 0.97, P = 0.04) and the rate of escalation of respiratory support (OR 0.45, 95% CI 0.31 to 0.67, P < 0.0001) when compared to COT. There was no difference in mortality between HFNC and COT utilization (OR 1.01, 95% CI 0.67 to 1.53, P = 0.96). When HFNC was compared to NIV, there was no difference in the intubation rate (OR 0.96; 95% CI 0.66 to 1.39, P = 0.84), the rate of escalation of respiratory support (OR 1.00, 95% CI 0.77 to 1.28, P = 0.97) or mortality (OR 0.85, 95% CI 0.43 to 1.68, P = 0.65).

Conclusions: Compared to COT, HFNC reduced the rate of intubation, mechanical ventilation and the escalation of respiratory support. When compared to NIV, HFNC showed no better outcomes. Large-scale randomized controlled trials are necessary to prove our findings.

Trial registration: PROSPERO International prospective register of systematic reviews on May 25, 2016 registration no. CRD42016039581 .

Keywords: Conventional oxygen therapy (COT); High-flow nasal cannula oxygen (HFNC); Intubation; Mortality; Noninvasive mechanical ventilation (NIV).

Fig. 1

Selection of studies included in this meta-analysis. RCT randomized controlled trial, HNFC high-flow nasal cannula oxygen

Fig. 2

Methodological quality of trials using the Cochrane risk of bias tool. Symbols show low risk of bias (+), unclear risk of bias (?) or high risk of bias (-)

Fig. 3

Overall risk of bias using the Cochrane risk of bias tool

Fig. 4

Funnel plot comparing of the intubation rate between high-flow nasal cannula oxygen (HFNC) and conventional oxygen therapy (COT) by Log odds ratio. OR odd ratio, SE standard error

Fig. 5

Comparison of intubation rates. a High-flow nasal cannula oxygen (HFNC) versus conventional oxygen therapy (COT). b HFNC versus noninvasive ventilation (NIV). CI confidence interval, M-H Mantel-Haenszel

Fig. 6

Comparison of secondary outcomes in patients who received high-flow nasal cannula oxygen (HFNC) compared to conventional oxygen therapy (COT). a Effect on the rate of mechanical ventilation. b Effect on the rate of escalation of respiratory support. c Effect on mortality. CI confidence interval, M-H Mantel-Haenszel

Fig. 7

Comparison of secondary outcomes in patients who received high-flow nasal cannula oxygen (HFNC) compared to noninvasive ventilation (NIV). a Effect on the rate of escalation of respiratory support. b Effect on mortality. CI confidence interval, M-H Mantel-Haenszel