High-flow nasal cannula oxygen therapy versus noninvasive ventilation in acute respiratory failure related to suspected or confirmed acute heart failure: a systematic review with meta-analysis

The objective of this review is to compare high-flow nasal cannula (HFNC) oxygen (High flow oxygen) and noninvasive ventilation (NIV) for the management of acute respiratory failure secondary to suspected or confirmed acute heart failure (AHF). A comprehensive and relevant literature search of MEDLINE, Web of Science, and the Cochrane Library was conducted using Medical Subject Heading and Free text terms from January 2010 to March 2024. All randomized clinical trials and observational retrospective and prospective studies reporting adult patients with acute respiratory failure due to suspected or confirmed AHF and comparing HFNC to NIV were included. Primary outcome included treatment failure, as a composite outcome including early termination to the allocated treatment, need for in-hospital intubation or mortality, or the definition used in the study for treatment failure if adequate. Secondary outcomes included change in respiratory rate and dyspnea intensity after treatment initiation, patient comfort, invasive mechanical ventilation requirement, and day-30 mortality. Six of the 802 identified studies were selected for final analysis, including 572 patients (221 assigned to high flow and 351 to NIV). Treatment failure rate was 20% and 13% in the high flow oxygen and NIV groups, respectively [estimated odds ratio (OR): 1.7, 95% confidence interval (95% CI): 0.9–3.1] in randomized studies and 34% and 16% in the high flow oxygen and NIV groups, respectively (OR: 3.1, 95% CI: 0.7–13.5), in observational studies. Tracheal intubation requirement was 7% and 5% of patients in the HFNC and NIV groups, respectively (OR: 1.4, 95% CI: 0.5–3.5) in randomized studies, and 20% and 9% in the high flow oxygen and NIV group, respectively (OR: 2.1, 95% CI: 0.5–9.4) in observational studies. Mortality was 13% and 8% in the high flow oxygen and the NIV groups, respectively (OR: 1.8, 95% CI: 0.8–1.1) in randomized studies and 14% and 9% in the high flow oxygen and the NIV groups, respectively (OR: 1.4, 95% CI: 0.5–3.7) in observational studies. Compared with NIV, high flow oxygen was not associated with a higher risk of treatment failure during initial management of patients with acute respiratory failure related to suspected or confirmed AHF.