High-Flow Nasal Cannula in Hypercapnic Respiratory Failure: A Systematic Review and Meta-Analysis

Although the efficacy and safety of high-flow nasal cannula (HFNC) in hypoxemic respiratory failure are widely recognized, it is yet unclear whether HFNC can effectively reduce the intubation rate and mortality in hypercapnic respiratory failure. We performed a systematic review and meta-analysis to assess the safety and efficiency of HFNC in these patients.

A systematic search of PubMed, Embase, and Cochrane Library (CENTRAL) was carried out. Two reviewers independently screened all references according to the inclusion criteria. We used the Cochrane risk-of-bias tool and the Newcastle-Ottawa Quality Assessment Scale to assess the quality of randomized controlled trials (RCTs) and cohort studies, respectively. Data from eligible trials were extracted for the meta-analysis.

Eight studies with a total of 621 participants were included (six RCTs and two cohort studies). Our analysis showed that HFNC is noninferior to noninvasive ventilation (NIV) with respect to intubation rate in both RCTs (OR = 0.92, 95% CI: 0.45-1.88) and cohort studies (OR = 0.94, 95% CI: 0.55-1.62). Similarly, the analysis of cohort studies showed no difference in reducing mortality rates (OR = 0.96, 95% CI: 0.42-2.20). Based on RCTs, NIV seemed more effective in reducing mortality (OR = 1.33, 95% CI: 0.68-2.60), but the intertreatment difference was not statistically significant. Furthermore, no significant differences were found between HFNC and NIV relating to change of blood gas analysis or respiratory rate (MD = -0.75, 95% CI: -2.6 to 1.09). Likewise, no significant intergroup differences were found with regard to intensive care unit stay (SMD = -0.07, 95% CI: 0.26 to 0.11). Due to a physiological friendly interface and variation, HFNC showed a significant advantage over NIV in patients' comfort and complication of therapy.

Despite the limitations noted, HFNC may be an effective and safe alternative to prevent endotracheal intubation and mortality when NIV is unsuitable in mild-to-moderate hypercapnia. Further high-quality studies are needed to validate these findings.