Introduction: High flow nasal cannula (HFNC) has been increasingly used in the treatment of respiratory failure and has recently been studied as an alternative to noninvasive ventilation (NIV) in patients with chronic obstructive pulmonary disease (COPD). This systematic review and meta-analysis aimed to evaluate the effects of HFNC in preventing treatment failure during COPD exacerbation as an initial treatment in comparison to NIV. Methods: We followed PRISMA guidelines to conduct this study and registered it with PROSPERO (CRD42024619821). We performed comprehensive literature search using PubMed, Embase, Cochrane and ClinicalTrials.gov through October 26th, 2024, to identify randomized controlled trials (RCTs) comparing HFNC and NIV in COPD exacerbation. The primary outcome was treatment failure, while the definition varied among different studies. Secondary outcomes included need for intubation, change in respiratory support, hospital mortality, duration of treatment, skin breakdown, and hospital length of stay. Treatment effects were estimated using fixed and random effects models. Subgroup analyses, trial sequential analysis, and GRADE assessment were performed. Results: 14 RCTs were included. Compared to NIV, HFNC had higher risk for treatment failure (13 RCTs, n=1325, RR 1.25 95% CI 1.02-1.55). However, the required sample size (n=3074) was not met. HFNC carried a higher risk of changes in respiratory support (9 RCTs, n=980; RR 1.53, 95% CI:1.08–2.17) and longer length of treatment (7 RCTs, n=871; MD 0.43, 95% CI 0.21 to 0.65 days). Conversely, the risk of skin breakdown was lower with HFNC (4 RCTs, n=586; RR 0.26, 95% CI: 0.12–0.56). No significant differences were found in the need for intubation (13 RCT, n=1325, RR 1.11, 95% CI 0.85-1.45), hospital length of stay (9 RCT,n=927, MD -0.46, 95% CI: -1.4 to 0.48 days), and hospital mortality (5 RCT, n=494, RR 0.92, 95% CI: 0.56-1.49). Conclusions: NIV appears more effective than HFNC in reducing treatment failure, the need for change in respiratory support, and treatment duration during COPD exacerbations. However, HFNC is associated with lower rates of skin breakdown.
Krell et al. (Sun,) studied this question.