Noninvasive respiratory support strategies in chest trauma: A systematic review and network meta-analysis

Background: Chest trauma often causes respiratory impairment and carries substantial mortality, particularly among intubated patients. Although guidelines recommend noninvasive ventilation (NIV) for hypoxemic respiratory failure, high flow nasal cannula (HFNC) is increasingly used despite limited comparative evidence. The objective was to compare the effects of conventional oxygen therapy (COT), HFNC, and NIV on escalation of respiratory support and in-hospital outcomes in adults with hypoxemic respiratory failure after chest trauma. Methods: We conducted a systematic review and network meta-analysis registered in UMIN (UMIN XXX) and reported according to PRISMA-NMA. MEDLINE, Cochrane Central, Cumulative Index to Nursing and Allied Health Literature, WHO International Clinical Trials Registry Platform, and ClinicalTrials.gov were searched from January 2000 to July 2025. Randomized controlled trials and high-quality observational studies were eligible if they compared at least two of COT, HFNC, and NIV in adults with hypoxemia due to chest trauma. The primary outcome was escalation of respiratory support; secondary outcomes were in-hospital mortality and length of hospital stay. A random-effects frequentist network meta-analysis was performed. Results: Four studies met eligibility criteria (three randomized trials and one observational study), including 3,270 patients: 1,465 received NIV, 1,613 HFNC, and 192 COT. Compared with COT, NIV was associated with a lower risk of escalation of respiratory support odds ratio (OR), 0.42; 95% CI, 0.20–0.85 and a lower escalation risk than HFNC (OR, 0.72; 95% CI, 0.58–0.89). HFNC showed uncertain benefit relative to COT (OR, 0.58; 95% CI, 0.29–1.16). NIV was also associated with lower in-hospital mortality and shorter hospital stay than both COT and HFNC. Reported device-related and clinical complications were uncommon. Conclusions: In adults with hypoxemic respiratory failure after chest trauma, NIV appears more effective than HFNC and COT in preventing escalation of respiratory support and improving in-hospital outcomes.(J Trauma Acute Care Surg. 2026;00:000–000. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.) Level of Evidence: Systematic review/meta-analyses; Level II.