Comparison between high-flow nasal cannula and conventional oxygen therapy in COVID-19 patients: a systematic review and meta-analysis

Abstract

Background: High-flow nasal cannula (HFNC) and conventional oxygen therapy (COT) are important respiratory support strategies for acute hypoxemic respiratory failure (AHRF) in coronavirus disease 2019 (COVID-19) patients. However, the results are conflicting for the risk of intubation with HFNC as compared to COT. Objectives: We systematically synthesized the outcomes of HFNC relative to COT in COVID-19 patients with AHRF and evaluated these outcomes in relevant subpopulations. Design: This study was designed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data sources and methods: We searched PubMed, EMBASE, Web of Science, Scopus, ClinicalTrials.gov, medRxiv, BioRxiv, and the Cochrane Central Register of Controlled Trials for randomized controlled trials and observational studies that compared the efficacy of HFNC with COT in patients with COVID-19-related AHRF. Primary outcomes were intubation rate and mortality rate. Secondary outcomes were the ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2), respiratory rate, hospital length of stay, intensive care unit (ICU) length of stay, and days free from invasive mechanical ventilation. Results: In total, 20 studies with 5732 patients were included. We found a decreased risk of requiring intubation in HFNC compared to COT [odds ratio (OR) = 0.61, 95% confidence interval (CI): 0.46–0.82, p = 0.0009, I2 = 75%]. Similarly, we found HFNC was associated with lower risk of intubation rate compared to COT in the subgroup of patients with baseline PaO2/FiO2 < 200 mmHg (OR = 0.69, 95% CI: 0.55–0.86, p = 0.0007, I2 = 45%), and who were in ICU settings at enrollment (OR = 0.57, 95% CI: 0.38–0.85, p = 0.005, I2 = 80%). HFNC was associated with an improvement of PaO2/FiO2 and respiratory rate compared to COT. The use of HFNC compared to COT did not reduce the mortality rate, days free from invasive mechanical ventilation, hospital length of stay, or ICU length of stay. Conclusion: Compared to COT, HFNC may decrease the need for tracheal intubation in patients with COVID-19-related AHRF, particularly among patients with baseline PaO2/FiO2 < 200 mmHg and those in ICU settings. Trial registration: This systematic review and meta-analysis protocol was prospectively registered with PROSPERO (no. CRD42022339072).

Predictors of high-flow nasal cannula failure in COVID-19 patients in a northern Peruvian hospital.

“…This is related to other studies where it ranges between 32 and 53% with maximums of 92% (11). In addition, Pisciotta W et al in a systematic review found failure rates between 11 and 69.3% with the use of HFNC ( 21) and Wang et al in another systematic review found failure rates in those with PaO2/FiO2 < 200 between 34-54% and values of 0-43% in those with PaO2/FiO2 > 20 (22). While Cárcamo P et al in the Peruvian population who used HFNC found device failure in 29.7%, these results do not coincide with our study, probably because in the population evaluated, 68% were under 60 years of age, while in our study and the rest of the detailed investigations the average age was 55-65 years, so we assume other factors such as comorbidities and frailty could also be present.…”

“…A study with a larger sample size is recommended, including a population with without multimorbidity, with or without other strategies such as prone, which were not evaluated in this study, to analyze the effectiveness of HFNC, and to measure different outcomes such as length of stay in the ICU, days free of MV, or mortality, which are detailed in other studies and important at the health care level (22). Furthermore, it is recommended to use predictor indices such as PaO2/FiO2, as they are an easy and cost-effective way to predict the failure of HFNC, but this should go hand in hand with an early estimation in cases of patients with ARDS, helping to improve survival rates and economizing resources.…”