Comparison of clinical outcomes between high-flow nasal cannula and non-invasive ventilation in acute exacerbation of COPD: a meta-analysis of randomized controlled trials

High-flow nasal cannula (HFNC) has recently emerged as a promising alternative to non-invasive ventilation (NIV) for patients with chronic obstructive pulmonary disease (COPD). However, direct comparative evidence on the clinical efficacy of HFNC versus NIV in acute exacerbations of COPD (AECOPD) remains limited and inconclusive. A systematic search of PubMed, EMBASE, Cochrane Library, and Web of Science was conducted up to January 2025 for randomized controlled trials (RCTs) comparing HFNC and NIV in AECOPD patients. Outcomes included mortality, treatment failure, intubation rates, and treatment intolerance. Nine RCTs involving 786 patients were included in the meta-analysis. No significant differences were observed in mortality (I2 = 0.0%, P = 0.818; RR 1.000, 95% CI 0.638 to 1.569, P = 0.999) or intubation rates (I2 = 22.1%, P = 0.253; RR 1.401, 95% CI 0.790 to 2.484, P = 0.249). Although HFNC significantly reduced treatment intolerance (I2 = 0.0%, P = 0.976; RR 0.145, 95% CI 0.048 to 0.438, P = 0.001), it showed a non-significant trend toward a higher treatment failure rate compared to NIV (I2 = 36.2%, P = 0.180; RR 1.553, 95% CI 0.955 to 2.524, P = 0.076). HFNC therapy showed a trend towards a higher treatment failure rate compared to NIV, though the difference was not statistically significant. No significant differences were found in mortality or intubation rates between the two groups.