Is high-flow nasal oxygen as effective as non-invasive ventilation in acute cardiogenic pulmonary Edema?

Acute cardiogenic pulmonary edema (ACPE) is a significant cause of emergency department (ED) visits due to dyspnea. Non-invasive ventilation (NIV) is currently the recommended first-line treatment for respiratory failure secondary to ACPE. The aim of this study is to compare the effectiveness of high-flow nasal cannula (HFNC) and NIV in improving respiratory rate (RR) and other clinical outcomes in adult patients presenting to the ED with ACPE.

This study was conducted as a prospective, randomized, single-center, superiority trial with a 1:1 parallel-group allocation. All consecutive adult patients (≥18 years) who presented to our emergency department between July 2023 and April 2024 were screened for eligibility. Those meeting the inclusion and exclusion criteria were enrolled and randomly assigned in a 1:1 ratio to receive either high-flow nasal cannula (HFNC) or non-invasive ventilation (NIV) therapy. All analyses were performed according to the intention-to-treat (ITT) principle, with per-protocol (PP) analyses also presented for comparison.

During the study period, 1376 patients were screened, and 178 were randomized. Baseline characteristics, including initial respiratory rates-34 (IQR, 30-38) breaths/min in the HFNC group and 33.5 (IQR, 30-37) in the NIV group-were similar between groups. In both intention-to-treat and per-protocol analyses, the change in respiratory rate at 120 min was similar across groups. No significant differences were observed in respiratory rates or their changes at 30, 60, and 120 min. Likewise, changes in other vital signs, arterial blood gas parameters, and dyspnea scores during follow-up did not differ significantly between the groups.

In this study, no difference was found between HFNC and NIV in reducing the symptoms and signs of respiratory failure with oxygen-ventilation support in patients with acute cardiogenic pulmonary edema. Considering that HFNC provides better patient tolerability and comfort, it may be considered a viable alternative to NIV in this specific patient population.