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Efficacy of HFNC + NIV as initial oxygen therapy in acute respiratory failure: Meta-analysis.

Weizhong Wang, Pan Zhang, Ting Xu, Haiying Guo, Weidong Liu, Shunfa Li, Yaoying Zhou

The American journal of emergency medicine · 2025-09-19 · Meta-analysis

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Abstract

BACKGROUND: Combining non-invasive ventilation (NIV) and high-flow nasal cannula (HFNC) may offer complementary benefits in acute respiratory failure (ARF). Prior meta-analyses compared monotherapies or post-extubation combination therapy, but none specifically evaluated NIV + HFNC as the initial strategy to prevent intubation or mortality. OBJECTIVES: To compare the efficacy of initial NIV + HFNC versus NIV or HFNC monotherapy for preventing intubation and mortality in adults with ARF. METHODS: We systematically searched PubMed, Embase, Cochrane Library, and Web of Science (inception to May 31, 2025) for relevant RCTs. Primary outcome was intubation rate; secondary outcome was mortality. Statistical data analysis was performed using RevMan software. Risk of bias was assessed (Cochrane RoB 2). RESULTS: Six RCTs (N = 764 participants) were included. Compared with monotherapy, combined NIV + HFNC did not significantly affect intubation rates (OR 1.08, 95 % CI 0.79-1.49; P = 0.62; I2 = 23 %) or mortality (OR 1.41, 95 % CI 0.60-3.34; P = 0.43; I2 = 62 %). Subgroup analyses by control intervention (NIV alone or HFNC alone) and trial design (single-center vs. multi-center) also showed no statistically significant differences. Notably, the largest studies exhibited contrasting trends, potentially attributable to variations in lung-protective ventilation strategies during NIV. CONCLUSIONS: This meta-analysis found no significant benefit of initial NIV + HFNC over monotherapy in reducing intubation or mortality in ARF. Future high-quality RCTs should prioritize standardized protocols, explicit lung-protective NIV settings, and larger sample sizes, with particular emphasis on specific ARF phenotypes that may derive maximal benefit from combined therapy.

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Tags

CPAP & NIV · High-flow nasal oxygen · Other drugs · Oxygen

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