Respiratory failure can be caused by a variety of diseases and can lead to death due to poor oxygenation. The role of non-invasive respiratory support has been debated. This meta-analysis assesses the effectiveness and reliability of HFNC, standard oxygen (SO) treatment and non-invasive ventilation (NIV) in patients with respiratory failure respectively. The PubMed, Cochrane library, and CNKI databases were systematically searched from the inception dates to March 1, 2022. The primary randomized clinical trials included in meta-analyses were identified. The participants were patients with acute respiratory failure. Hospitalization mortality was defined as the primary outcome. Secondary outcomes were Failure of ventilation, Infection. The PROSPERO database has been registered with this meta-analysis. (registration number: CRD42022320088, 03/26/2022). A total of 26 RCTs involving 6518 patients were included. HFNC did not differ from NIV or SO therapy in terms of hospitalization mortality, ventilation failure, or lung infection. Patients with acute respiratory failure treaded with HFNC were more likely to develop remaining organ failure during hospitalization than those treated with NIV (P = 0.002, I² = 0%). Compared to SO, the use of HFNC leads to a more comfortable experience to patients (P=0.0003, I²=0%) and increase the oxygen partial pressure (P=0.001, I²=0%). In the subgroup analysis results of COVID-19, there were no significant differences between the HFNC, SO, and NIV for intervention failure, hospital mortality and oxygenation index. In hemodynamically stable patients with acute respiratory failure, there was no significant difference in in-hospital mortality and intervention failure rates between HFNC and SO and NIV. HFNC was superior to SO in improving patient oxygen partial pressure and comfort. In addition, there was no significant efficacy difference between NIV and SO for HFNC in the treatment of acute respiratory failure in COVID-19 patients.

Qinhong Dai, Shihui Lin, Wei Huang, Fang Xu, Jixiang Tan. Safety and Efficacy of High-flow Nasal Cannula (HFNC) Versus Non-invasive Ventilation in Patients with Respiratory Failure: A Meta-analysis. International Journal of Frontiers in Medicine (2024), Vol. 6, Issue 1: 1-13. https://doi.org/10.25236/IJFM.2024.060101.

[1] Spoletini, G., et al.: High-flow nasal therapy vs standard oxygen during breaks off noninvasive ventilation for acute respiratory failure: a pilot randomized controlled trial. J. Crit. Care 48(2018 Issue 11), 418-425 (2018) https://doi.org/10.1016/j.jcrc.2018.10.004

[2] Fan, E., Brodie, D., Slutsky, A.S.: Acute respiratory distress syndrome: advances in diagnosis and treatment. JAMA-J. Am. Med. Assoc. 319(7), 698-710 (2018) https://doi.org/10.1001/jama.2017.21907

[3] Conrad, S.A., Bidani, A.: Management of the acute respiratory distress syndrome. Chest Surg Clin N Am 12(2), 325-354 (2002) https://doi.org/10.1016/s1052-3359 (02)00012-1

[4] Crouser, E.D., Dorinsky, P.M.: Gastrointestinal tract dysfunction in critical illness: pathophysiology and interaction with acute lung injury in adult respiratory distress syndrome/ multiple organ dysfunction syndrome. New Horiz 2(4), 476-487 (1994)

[5] Li, J.B., Zhang, L., Zhu, K.M., Deng, X.M.: Retrospective analysis on acute respiratory distress syndrome in icu. Chin. J. Traumatol. 10(4), 200-205 (2007) 

[6] Shi, M., et al.: Analysis of clinical features and outcomes of 161 patients with severe and critical covid-19: a multicenter descriptive study. J. Clin. Lab. Anal. 34(9), e23415 (2020) https://doi.org/ 10.1002/jcla.23415

[7] Vincent, J.L., Zambon, M.: Why do patients who have acute lung injury/acute respiratory distress syndrome die from multiple organ dysfunction syndrome? Implications for management. Clin. Chest Med. 27(4), 725-731 (2006) https://doi.org/10.1016/j.ccm.2006.06.010

[8] Huppert, L.A., Matthay, M.A., Ware, L.B.: Pathogenesis of acute respiratory distress syndrome. Semin. Respir. Crit. Care Med. 40(1), 31-39 (2019) https://doi.org/10.1055/s-0039-1683996

[9] Lamba, T.S., Sharara, R.S., Singh, A.C., Balaan, M.: Pathophysiology and classification of respiratory failure. Crit. Care Nurs. Q. 39(2), 85-93 (2016) https://doi.org/10.1097/CNQ. 0000000000000102

[10] Hornik, C., Meliones, J.: Pulmonary edema and hypoxic respiratory failure. Pediatr. Crit. Care Med. 17(8 Suppl 1), S178-S181 (2016) https://doi.org/10.1097/PCC.0000000000000823

[11] Sachdev, G., Napolitano, L.M.: Postoperative pulmonary complications: pneumonia and acute respiratory failure. Surg. Clin.-North Am. 92(2), 321-344 (2012) https://doi.org/10.1016/j. suc. 2012.01.013

[12] Narendra, D.K., et al.: Update in management of severe hypoxemic respiratory failure. Chest 152(4), 867-879 (2017) https://doi.org/10.1016/j.chest.2017.06.039

[13] Williams, G.W., Berg, N.K., Reskallah, A., Yuan, X., Eltzschig, H.K.: Acute respiratory distress syndrome. Anesthesiology 134(2), 270-282 (2021) https://doi.org/10.1097/ALN.0000000000003571

[14] Saguil, A., Fargo, M.V.: Acute respiratory distress syndrome: diagnosis and management. Am. Fam. Physician 101(12), 730-738 (2020) 

[15] Grieco, D.L., et al.: Non-invasive ventilatory support and high-flow nasal oxygen as first-line treatment of acute hypoxemic respiratory failure and ards. Intensive Care Med. 47(8), 851-866 (2021) https://doi.org/10.1007/s00134-021-06459-2

[16] Brochard, L., Slutsky, A., Pesenti, A.: Mechanical ventilation to minimize progression of lung injury in acute respiratory failure. Am. J. Respir. Crit. Care Med. 195(4), 438-442 (2017) https://doi.org/10.1164/rccm.201605-1081CP

[17] Mas, A., Masip, J.: Noninvasive ventilation in acute respiratory failure. Int. J. Chronic Obstr. Pulm. Dis. 9(837-852 (2014) https://doi.org/10.2147/COPD.S42664

[18] Ni, Y.N., et al.: Can high-flow nasal cannula reduce the rate of endotracheal intubation in adult patients with acute respiratory failure compared with conventional oxygen therapy and noninvasive positive pressure ventilation?: A systematic review and  meta-analysis. Chest 151(4), 764-775 (2017) https://doi.org/10.1016/j.chest.2017.01.004

[19] Lentz, S., et al.: Initial emergency department mechanical ventilation strategies for covid-19 hypoxemic respiratory failure and ards. Am. J. Emerg. Med. 38(10), 2194-2202 (2020) https://doi.org/10.1016/j.ajem.2020.06.082

[20] Matthay, M.A., et al.: Acute respiratory distress syndrome. Nat. Rev. Dis. Primers 5(1), 18 (2019) https://doi.org/10.1038/s41572-019-0069-0

[21] Goligher, E.C., Ferguson, N.D., Brochard, L.J.: Clinical challenges in mechanical ventilation. Lancet 387(10030), 1856-1866 (2016) https://doi.org/10.1016/S0140-6736 (16)30176-3

[22] Nishimura, M.: High-flow nasal cannula oxygen therapy devices. Respir. Care 64(6), 735-742 (2019) https://doi.org/10.4187/respcare.06718

[23] Nishimura, M.: High-flow nasal cannula oxygen therapy in adults: physiological benefits, indication, clinical benefits, and adverse effects. Respir. Care 61(4), 529-541 (2016) https://doi.org/ 10.4187/respcare.04577

[24] Reimer, A.P., et al.: High-flow nasal cannula in transport: process, results, and considerations. Air Med J 41(1), 42-46 (2022) https://doi.org/10.1016/j.amj.2021.09.008

[25] Oczkowski, S., et al.: Ers clinical practice guidelines: high-flow nasal cannula in acute respiratory failure. Eur. Resp. J. 59(4) (2022) https://doi.org/10.1183/13993003.01574-2021

[26] Raoof, S., Nava, S., Carpati, C., Hill, N.S.: High-flow, noninvasive ventilation and awake (nonintubation) proning in patients with coronavirus disease 2019 with respiratory failure. Chest 158(5), 1992-2002 (2020) https://doi.org/10.1016/j.chest.2020.07.013

[27] Ali, S., Ferguson, N.D.: High-frequency oscillatory ventilation in ali/ards. Crit. Care Clin. 27(3), 487-499 (2011) https://doi.org/10.1016/j.ccc.2011.04.006

[28] Schmid, B., et al.: Awake prone positioning, high-flow nasal oxygen and non-invasive ventilation as non-invasive respiratory strategies in covid-19 acute respiratory failure: a systematic review and meta-analysis. J. Clin. Med. 11(2), 391 (2022) https://doi.org/10.3390/jcm11020391

[29] Zhang, X., et al.: Aceso: pico-guided evidence summarization on medical literature. IEEE J. Biomed. Health Inform. 24(9), 2663-2670 (2020) https://doi.org/10.1109/JBHI.2020.2984704

[30] Lewis, S.R., Baker, P.E., Parker, R., Smith, A.F.: High-flow nasal cannulae for respiratory support in adult intensive care patients. Cochrane Database Syst Rev. 3(3), CD10172 (2021) https://doi.org/10.1002/14651858.CD010172.pub3

[31] Frat, J.P., et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N. Engl. J. Med. 372(23), 2185-2196 (2015) https://doi.org/10.1056/NEJMoa1503326

[32] Nair, P.R., et al. Comparison of high-flow nasal cannula and noninvasive ventilation in acute hypoxemic respiratory failure due to severe covid-19 pneumonia. Respir. Care 66(12), 1824-1830 (2021) https://doi.org/10.4187/respcare.09130

[33] Zhan, Q., et al. Early use of noninvasive positive pressure ventilation for acute lung injury: a multicenter randomized controlled trial. Crit. Care Med. 40(2), 455-460 (2012) https://doi.org/ 10.1097/CCM.0b013e318232d75e

[34] Shebl, E., Embarak, S. High-flow nasal oxygen therapy versus noninvasive ventilation in chronic interstitial lung disease patients with acute respiratory failure. The Egyptian Journal of Chest Diseases and Tuberculosis 270(2018, 67), 275 (2018) https://doi.org/10.4103/ejcdt.ejcdt_33_18

[35] Grieco, D.L., et al. Effect of helmet noninvasive ventilation vs high-flow nasal oxygen on days free of respiratory support in patients with covid-19 and moderate to severe hypoxemic respiratory failure: the henivot randomized clinical trial. JAMA-J. Am. Med. Assoc. 325(17), 1731-1743 (2021) https://doi.org/10.1001/jama.2021.4682

[36] Perkins, G.D., et al.: Effect of noninvasive respiratory strategies on intubation or mortality among patients with acute hypoxemic respiratory failure and covid-19: the recovery-rs randomized clinical trial. JAMA-J. Am. Med. Assoc. 327(6), 546-558 (2022) https://doi.org/10.1001/jama.2022.0028

[37] Ospina-Tascón, G.A., et al.: Effect of high-flow oxygen therapy vs conventional oxygen therapy on invasive mechanical ventilation and clinical recovery in patients with severe covid-19: a randomized clinical trial. JAMA-J. Am. Med. Assoc. 326(21), 2161-2171 (2021) https://doi.org/ 10. 1001/ jama.2021.20714

[38] Jean-Pierre Frat, M.P., et al.: Effect of high-flow nasal cannula oxygen vs standard oxygen therapy on mortality in patients with respiratory failure due to covid-19. JAMA-J. Am. Med. Assoc. 328(12)(2022), 1212-1222 (2022) https://doi.org/10. 1001/jama. 2022. 15613

[39] Azoulay, E., et al.: Effect of high-flow nasal oxygen vs standard oxygen on 28-day mortality in immunocompromised patients with acute respiratory failure: the high randomized clinical trial. JAMA-J. Am. Med. Assoc. 320(20), 2099-2107 (2018) https://doi.org/10.1001/jama.2018.14282

[40] Hu, T., et al.: Effect of high-flow nasal oxygen vs. Conventional oxygen therapy on extubation outcomes and physiologic changes for patients with high risk of extubation failure in the medical icu: a tertiary center, randomized, controlled trial. Int. J. Gerontol. 1(14), 36-41 (2020)

[41] Song, Gu, Xiu, Cui, Zhang: The value of high-flow nasal cannula oxygen therapy after extubation in patients with acute respiratory failure. Clin. Sci. 9(72), 562-567 (2017) https://doi.org/ 10.6061/ clinics/2017(09)07

[42] Antonicelli, F., et al.: High-flow oxygen therapy through nasal cannulae versus low-flow oxygen therapy via venturi mask after extubation in adult, critically ill patients. Crit. Care 15(2011), S59 (2011) https://doi.org/10.1186/cc9585)

[43] Jones, P.G., Kamona, S., Doran, O., Sawtell, F., Wilsher, M.: Randomized controlled trial of humidified high-flow nasal oxygen for acute respiratory distress in the emergency department: the hot-er study. Respir. Care 61(3), 291-299 (2016) https://doi.org/10.4187/respcare.04252

[44] Yu, Y., Qian, X., Liu, C., Zhu, C.: Effect of high-flow nasal cannula versus conventional oxygen therapy for patients with thoracoscopic lobectomy after extubation. Can. Respir. J. 2017(2017), 7894631 (2017) https://doi.org/10.1155/2017/7894631

[45] Futier, E., et al.: Effect of early postextubation high-flow nasal cannula vs conventional oxygen therapy on hypoxaemia in patients after major abdominal surgery: a french multicentre randomised controlled trial (opera). Intensive Care Med. 42(12), 1888-1898 (2016) https://doi.org/ 10.1007/ s00134-016-4594-y

[46] Lemiale, V., et al.: The effects of a 2-h trial of high-flow oxygen by nasal cannula versus venturi mask in immunocompromised patients with hypoxemic acute respiratory failure: a multicenter randomized trial. Crit. Care 19(380 (2015) https://doi.org/10.1186/s13054-015-1097-0

[47] Maggiore, S.M., et al.: Nasal high-flow versus venturi mask oxygen therapy after extubation. Effects on oxygenation, comfort, and clinical outcome. Am. J. Respir. Crit. Care Med. 190(3), 282-288 (2014) https://doi.org/10.1164/rccm.201402-0364OC

[48] Hernández, G., et al.: Effect of postextubation high-flow nasal cannula vs noninvasive ventilation on reintubation and postextubation respiratory failure in high-risk patients: a randomized clinical trial. JAMA-J. Am. Med. Assoc. 316(15), 1565-1574 (2016) https://doi.org/10.1001/jama.2016.14194

[49] Teng, X., et al.: The value of high-flow nasal cannula oxygen therapy in treating novel coronavirus pneumonia. Eur. J. Clin. Invest. e(2020), 13435 (2020) https://doi.org/10.1111/eci.13435

[50] Li, S.N., Li, L., Li, C.L., Zhou, S.P., Lu, W. C.: The safety and effectiveness of heated humidified high-flow nasal cannula as an initial ventilation method in the treatment of neonatal respiratory distress syndrome: a protocol for systematic review and meta-analysis. Medicine (Baltimore) 99(46), e23243 (2020) https://doi.org/10.1097/MD.0000000000023243

[51] Lin, X., Jia, P., Li, X.Q., Liu, Q. Efficacy of high-flow nasal cannula versus nasal continuous positive airway pressure in the treatment of respiratory distress syndrome in neonates: a meta analysis. Zhongguo Dang Dai Er Ke Za Zhi 22(11), 1164-1171 (2020) https://doi.org/10.7499/j. issn. 1008-8830.2005102

[52] Rochwerg, B., et al.: The role for high fow nasal cannula as a respiratory support strategy in adults: a clinical practice guideline. Intensive Care Med. 46), 2226-2237 (2020) 

[53] Artigas, R.M., et al.: High‑fow nasal oxygen in patients with covid‑19‑associated acute respiratory failure. Mellado‑Artigas et al. Crit Care), 25-58 (2021) https://doi.org/ https:// doi.org/10.1186/s13054-021-03469-w

[54] Network, C.G.O.B., Investigators, T.C.: Clinical characteristics and day-90 outcomes of 4244 critically ill adults with covid-19: a prospective cohort study. Intensive Care Med.47), 60-73 (2021) https://doi.org/https://doi.org/10.1007/s00134-020-06294-x

[55] Yasuda, H., Okano, H., Mayumi, T., Nakane, M., Shime, N.: Association of noninvasive respiratory support with mortality and intubation rates in acute respiratory failure: a systematic review and network meta-analysis. J. Intensive Care 9(1), 32 (2021) 

[56] Hernández, G., et al.: Effect of postextubation noninvasive ventilation with active humidification vs high‑flow nasal cannula on reintubation in patients at very high risk for extubation failure: a randomized trial. Intensive Care Med. (2022) https://doi.org/10.1007/s00134-022-06919-3.