High-flow nasal cannula (HFNC) was associated with a lower intubation rate compared with conventional oxygen therapy (COT) in patients hospitalized with COVID-19, according to a study in Therapeutic Advances in Respiratory Disease.
The results are from a systematic review and meta-analysis of clinical trials comparing intubation risk in patients with COVID-19-related acute hypoxemic respiratory failure who used HFNC vs COT.
The researchers searched for relevant studies in PubMed, EMBASE, Web of Science, Scopus, ClinicalTrials.gov, medRxiv, BioRxiv, and the Cochrane Central Register of Controlled Trials from January 1, 2020, to October 1, 2022. Eligible randomized controlled trials (RCTs) and observational studies included adult patients (aged ≥16 years) with COVID-19-related AHRF who received HFNC compared with COT. The primary outcome was intubation rate (at 28 days or in-hospital).
The meta-analysis included 20 studies (8 RCTs and 12 observational studies), with 5732 patients.
“
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 mm Hg and those in ICU settings.
Endotracheal intubation outcomes were reported in 17 studies (5547 patients). Results showed that HFNC may decrease the need for invasive mechanical ventilation compared with COT (odds ratio [OR], 0.61; 95% CI, 0.46-0.82; P =.0009, I2 = 75%). Subgroup analyses revealed a reduced intubation rate in the HFNC group in patients with a baseline ratio of partial pressure of arterial oxygen to fractional inspired oxygen (PaO2/FiO2) of less than 200 mm Hg (P =.0007), but not in those with baseline PaO2/FiO2 more than 200 mm Hg (P =.20). Comparable findings were observed in patients in intensive care unit (ICU) settings at enrollment (P =.005), but not in those in non-ICU settings (P =.45).
Mortality was reported in all 20 studies, and no evidence of a difference was found for HFNC compared with COT (OR, 0.84; 95% CI, 0.67-1.06; P =.15, I2 =51%).
Among other findings, increased mean PaO2/FiO2 levels were observed at 4 to 6 hours (mean difference [MD]=29.46; 95% CI, 23.31-35.61; P <.00001; I2 =0%; 2 included studies) and 24 hours (MD=30.14; 95% CI, 13.12-47.16; P =.0005; I2 =41%; 2 included studies), as well as reduced respiratory rate at 4 to 6 hours (M= −1.95; 95% CI, −2.23 to 1.67; P <.00001; I2 =0%; 2 included studies) in the HFNC group vs the COT group.
No differences occurred between the HFNC and COT groups in days free from invasive mechanical ventilation, hospital length of stay, and ICU length of stay.
Among several limitations, the findings were based non-RCT studies as well as RCTs. Also, crossovers existed between groups in some studies and were not allowed in other studies. Furthermore, only a few studies reported accurate HFNC settings, and they were observed and recorded unsystematically.
The study authors concluded that “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 mm Hg and those in ICU settings.”
