Comparison of the efficacy and comfort of high-flow nasal cannula with different initial flow settings in patients with acute hypoxemic respiratory failure: a systematic review and network meta-analysis

Yuewen He, Xuhui Zhuang, Hao Liu, Wuhua Ma, Yuewen He, Xuhui Zhuang, Hao Liu, Wuhua Ma

Abstract

Background: High-flow nasal cannula (HFNC) has been proven effective in improving patients with acute hypoxemic respiratory failure (AHRF), but a discussion of its use for initial flow settings still need to be provided. We aimed to compare the effectiveness and comfort evaluation of HFNC with different initial flow settings in patients with AHRF.

Methods: Studies published by October 10, 2022, were searched exhaustively in PubMed, Embase, Web of Science, Cochrane Library (CENTRAL), and the China National Knowledge Infrastructure (CNKI) database. Network meta-analysis (NMA) was performed with STATA 17.0 and R software (version 4.2.1). A Bayesian framework was applied for this NMA. Comparisons of competing models based on the deviance information criterion (DIC) were used to select the best model for NMA. The primary outcome is the intubation at day 28. Secondary outcomes included short-term and long-term mortality, comfort score, length of ICU or hospital stay, and 24-h PaO2/FiO2.

Results: This NMA included 23 randomized controlled trials (RCTs) with 5774 patients. With NIV as the control, the HFNC_high group was significantly associated with lower intubation rates (odds ratio [OR] 0.72 95% credible interval [CrI] 0.56 to 0.93; moderate quality evidence) and short-term mortality (OR 0.81 95% CrI 0.69 to 0.96; moderate quality evidence). Using HFNC_Moderate (Mod) group (mean difference [MD] - 1.98 95% CrI -3.98 to 0.01; very low quality evidence) as a comparator, the HFNC_Low group had a slight advantage in comfort scores but no statistically significant difference. Of all possible interventions, the HFNC_High group had the highest probability of being the best in reducing intubation rates (73.04%), short-term (82.74%) and long-term mortality (67.08%). While surface under the cumulative ranking curve value (SUCRA) indicated that the HFNC_Low group had the highest probability of being the best in terms of comfort scores.

Conclusions: The high initial flow settings (50-60 L/min) performed better in decreasing the occurrence of intubation and mortality, albeit with poor comfort scores. Treatment of HFNC for AHRF patients ought to be initiated from moderate flow rates (30-40 L/min), and individualized flow settings can make HFNC more sensible in clinical practice.

Keywords: Acute hypoxemic respiratory failure; High-flow nasal cannula; Network meta-analysis.

Conflict of interest statement

The authors declare that they have no competing interests.

© 2023. The Author(s).

Figures

Fig. 1
Fig. 1
PRISMA flow diagram of the search strategy and included studies
Fig. 2
Fig. 2
Network plot of intubation at day 28 (A) and comfort scores (B). The size of the node represents the number of participants who received the intervention. The thickness of lines connecting nodes represents the number of studies for that comparison
Fig. 3
Fig. 3
Forest plots of network meta-analysis. Intubation at day 28, short-term and long-term mortality were shown in A. Comfort scores, length of ICU stay and hospital stay, and 24-h PaO2/FiO2 were shown in B
Fig. 4
Fig. 4
Line chart and bar chart of the surface under the cumulative ranking curve (SUCRA) values for intubation at day 28 (A) and comfort scores (B). The x-axis is the ranking of the initial flow rate setting and the y-axis is the cumulative probability of a particular ranking

References

    1. Oczkowski S, Ergan B, Bos L, Chatwin M, Ferrer M, Gregoretti C, et al. ERS clinical practice guidelines: high-flow nasal cannula in acute respiratory failure. Eur Respir J. 2022;59(4):2101574. doi: 10.1183/13993003.01574-2021.
    1. Coudroy R, Frat JP, Boissier F, Contou D, Robert R, Thille AW. Early identification of acute respiratory distress syndrome in the absence of positive pressure ventilation: implications for revision of the berlin criteria for acute respiratory distress syndrome. Crit Care Med. 2018;46(4):540–546. doi: 10.1097/CCM.0000000000002929.
    1. Piraino T. Noninvasive respiratory support in acute hypoxemic respiratory failure. Respir Care. 2019;64(6):638–646. doi: 10.4187/respcare.06735.
    1. Grieco DL, Maggiore SM, Roca O, Spinelli E, Patel BK, Thille AW, et al. Non-invasive ventilatory support and high-flow nasal oxygen as first-line treatment of acute hypoxemic respiratory failure and ARDS. Intensive Care Med. 2021;47(8):851–866. doi: 10.1007/s00134-021-06459-2.
    1. Pham T, Pesenti A, Bellani G, Rubenfeld G, Fan E, Bugedo G, et al. Outcome of acute hypoxaemic respiratory failure: insights from the LUNG SAFE Study. Eur Respir J. 2021;57(6):2003317. doi: 10.1183/13993003.03317-2020.
    1. Ranieri VM, Suter PM, Tortorella C, De Tullio R, Dayer JM, Brienza A, et al. Effect of mechanical ventilation on inflammatory mediators in patients with acute respiratory distress syndrome: a randomized controlled trial. JAMA. 1999;282(1):54–61. doi: 10.1001/jama.282.1.54.
    1. Coppola S, Caccioppola A, Froio S, Formenti P, De Giorgis V, Galanti V, et al. Effect of mechanical power on intensive care mortality in ARDS patients. Crit Care. 2020;24(1):246. doi: 10.1186/s13054-020-02963-x.
    1. Nay MA, Fromont L, Eugene A, Marcueyz JL, Mfam WS, Baert O, et al. High-flow nasal oxygenation or standard oxygenation for gastrointestinal endoscopy with sedation in patients at risk of hypoxaemia: a multicentre randomised controlled trial (ODEPHI trial) Br J Anaesth. 2021;127(1):133–142. doi: 10.1016/j.bja.2021.03.020.
    1. Spoletini G, Alotaibi M, Blasi F, Hill NS. Heated humidified high-flow nasal oxygen in adults: mechanisms of action and clinical implications. Chest. 2015;148(1):253–261. doi: 10.1378/chest.14-2871.
    1. Rochwerg B, Einav S, Chaudhuri D, Mancebo J, Mauri T, Helviz Y, et al. The role for high flow nasal cannula as a respiratory support strategy in adults: a clinical practice guideline. Intensive Care Med. 2020;46(12):2226–2237. doi: 10.1007/s00134-020-06312-y.
    1. Li J, Tu M, Yang L, Jing G, Fink JB, Burtin C, et al. Worldwide clinical practice of high-flow nasal cannula and concomitant aerosol therapy in the adult ICU setting. Respir Care. 2021;66(9):1416–1424. doi: 10.4187/respcare.08996.
    1. Miller AG, Gentle MA, Tyler LM, Napolitano N. High-flow nasal cannula in pediatric patients: a survey of clinical practice. Respir Care. 2018;63(7):894–899. doi: 10.4187/respcare.05961.
    1. Delorme M, Bouchard PA, Simon M, Simard S, Lellouche F. Effects of high-flow nasal cannula on the work of breathing in patients recovering from acute respiratory failure. Crit Care Med. 2017;45(12):1981–1988. doi: 10.1097/CCM.0000000000002693.
    1. Mauri T, Alban L, Turrini C, Cambiaghi B, Carlesso E, Taccone P, et al. Optimum support by high-flow nasal cannula in acute hypoxemic respiratory failure: effects of increasing flow rates. Intensive Care Med. 2017;43(10):1453–1463. doi: 10.1007/s00134-017-4890-1.
    1. Lemiale V, Resche-Rigon M, Mokart D, Pène F, Argaud L, Mayaux J, et al. High-flow nasal cannula oxygenation in immunocompromised patients with acute hypoxemic respiratory failure: a groupe de recherche respiratoire en réanimation onco-hématologique study. Crit Care Med. 2017;45(3):e274–e280. doi: 10.1097/CCM.0000000000002085.
    1. Azoulay E, Lemiale V, Mokart D, Nseir S, Argaud L, Pène F, et al. Effect of high-flow nasal oxygen vs standard oxygen on 28-day mortality in immunocompromised patients with acute respiratory failure: the HIGH randomized clinical trial. JAMA. 2018;320(20):2099–2107. doi: 10.1001/jama.2018.14282.
    1. Theologou S, Ischaki E, Zakynthinos SG, Charitos C, Michopanou N, Patsatzis S, et al. High flow oxygen therapy at two initial flow settings versus conventional oxygen therapy in cardiac surgery patients with postextubation hypoxemia: a single-center, unblinded, randomized, controlled trial. J Clin Med. 2021;10(10):2079. doi: 10.3390/jcm10102079.
    1. Wan X, Wang W, Liu J, Tong T. Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol. 2014;14:135. doi: 10.1186/1471-2288-14-135.
    1. Higgins JPT, Savović J, Page MJ, Elbers RG, Sterne JAC. Chapter 8: Assessing risk of bias in a randomized trial. In: Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (editors). Cochrane Handbook for Systematic Reviews of Interventions version 6.3 (updated February 2022). Cochrane, 2022. Available from .
    1. Li J, Scott JB, Fink JB, Reed B, Roca O, Dhand R. Optimizing high-flow nasal cannula flow settings in adult hypoxemic patients based on peak inspiratory flow during tidal breathing. Ann Intensive Care. 2021;11(1):164. doi: 10.1186/s13613-021-00949-8.
    1. Butt S, Pistidda L, Floris L, Liperi C, Vasques F, Glover G, et al. Initial setting of high-flow nasal oxygen post extubation based on mean inspiratory flow during a spontaneous breathing trial. J Crit Care. 2021;63:40–44. doi: 10.1016/j.jcrc.2020.12.022.
    1. Spiegelhalter DJ, Best NG, Carlin BP, Van Der Linde A. Bayesian measures of model complexity and fit. J R Stat Soc Ser B (Stat Methodol) 2002;64(4):583–639. doi: 10.1111/1467-9868.00353.
    1. Béliveau A, Boyne DJ, Slater J, Brenner D, Arora P. BUGSnet: an R package to facilitate the conduct and reporting of Bayesian network Meta-analyses. BMC Med Res Methodol. 2019;19(1):196. doi: 10.1186/s12874-019-0829-2.
    1. Salanti G, Ades AE, Ioannidis JP. Graphical methods and numerical summaries for presenting results from multiple-treatment meta-analysis: an overview and tutorial. J Clin Epidemiol. 2011;64(2):163–171. doi: 10.1016/j.jclinepi.2010.03.016.
    1. Brignardello-Petersen R, Izcovich A, Rochwerg B, Florez ID, Hazlewood G, Alhazanni W, et al. GRADE approach to drawing conclusions from a network meta-analysis using a partially contextualised framework. BMJ. 2020;371:m3907. doi: 10.1136/bmj.m3907.
    1. Yepes-Nuñez JJ, Li SA, Guyatt G, Jack SM, Brozek JL, Beyene J, et al. Development of the summary of findings table for network meta-analysis. J Clin Epidemiol. 2019;115:1–13. doi: 10.1016/j.jclinepi.2019.04.018.
    1. Frat JP, Quenot JP, Badie J, Coudroy R, Guitton C, Ehrmann S, et al. Effect of high-flow nasal cannula oxygen vs standard oxygen therapy on mortality in patients with respiratory failure due to COVID-19: the SOHO-COVID randomized clinical trial. JAMA. 2022;328(12):1212–1222. doi: 10.1001/jama.2022.15613.
    1. Grieco DL, Menga LS, Cesarano M, Rosà T, Spadaro S, Bitondo MM, et al. Effect of helmet noninvasive ventilation vs high-flow nasal oxygen on days free of respiratory support in patients with COVID-19 and moderate to severe hypoxemic respiratory failure: the HENIVOT randomized clinical trial. JAMA. 2021;325(17):1731–1743. doi: 10.1001/jama.2021.4682.
    1. Nair PR, Haritha D, Behera S, Kayina CA, Maitra S, Anand RK, et al. Comparison of high-flow nasal cannula and noninvasive ventilation in acute hypoxemic respiratory failure due to severe COVID-19 pneumonia. Respir Care. 2021;66(12):1824–1830. doi: 10.4187/respcare.09130.
    1. Ospina-Tascón GA, Calderón-Tapia LE, García AF, Zarama V, Gómez-Álvarez F, Álvarez-Saa T, et al. Effect of high-flow oxygen therapy vs conventional oxygen therapy on invasive mechanical ventilation and clinical recovery in patients with severe COVID-19: a randomized clinical trial. JAMA. 2021;326(21):2161–2171. doi: 10.1001/jama.2021.20714.
    1. Perkins GD, Ji C, Connolly BA, Couper K, Lall R, Baillie JK, et al. Effect of noninvasive respiratory strategies on intubation or mortality among patients with acute hypoxemic respiratory failure and COVID-19: the RECOVERY-RS randomized clinical trial. JAMA. 2022;327(6):546–558. doi: 10.1001/jama.2022.0028.
    1. Coudroy R, Frat JP, Ehrmann S, Pène F, Decavèle M, Terzi N, et al. High-flow nasal oxygen alone or alternating with non-invasive ventilation in critically ill immunocompromised patients with acute respiratory failure: a randomised controlled trial. Lancet Respir Med. 2022;10(7):641–649. doi: 10.1016/S2213-2600(22)00096-0.
    1. Lemiale V, Mokart D, Mayaux J, Lambert J, Rabbat A, Demoule A, et al. The effects of a 2-h trial of high-flow oxygen by nasal cannula versus Venturi mask in immunocompromised patients with hypoxemic acute respiratory failure: a multicenter randomized trial. Crit Care. 2015;19:380. doi: 10.1186/s13054-015-1097-0.
    1. Alptekinoğlu Mendil N, Temel Ş, Yüksel RC, Gündoğan K, Eser B, Kaynar L, et al. The use of high-flow nasal oxygen vs standard oxygen therapy in hematological malignancy patients with acute respiratory failure in hematology wards. Turk J Med Sci. 2021;51(4):1756–1763. doi: 10.3906/sag-2007-228.
    1. Liu X, Zhang W. Effect analysis of HFNC and NPPV in treatment of acute hypoxic respiratory failure. J Clin Pulm Med. 2018;1401–5.
    1. Andino R, Vega G, Pacheco SK, Arevalillo N, Leal A, Fernández L, et al. High-flow nasal oxygen reduces endotracheal intubation: a randomized clinical trial. Ther Adv Respir Dis. 2020;14:1753466620956459. doi: 10.1177/1753466620956459.
    1. Bell N, Hutchinson CL, Green TC, Rogan E, Bein KJ, Dinh MM. Randomised control trial of humidified high flow nasal cannulae versus standard oxygen in the emergency department. Emerg Med Australas. 2015;27(6):537–541. doi: 10.1111/1742-6723.12490.
    1. Qiao L, Qian L, Cao Y, Xu P, Liu H, Liu Y. Therapeutic efficacy of HFNC and conventional oxygen therapy in the adjuvant therapy of acute ischemic stroke patients complicated with type I respiratory failure: a comparative study. Pract J Cardiac Cereb Pneumal Vasc Dis. 2021;02:98–102.
    1. Feng X, Zhang G, Zeng L, Yang T, Deng F, Ye W. A randomized controlled trial of nasal high-flow oxygen therapy for acute respiratory failure. Chin J Respir Crit Care Med. 2020;19:489–494.
    1. Frat JP, Thille AW, Mercat A, Girault C, Ragot S, Perbet S, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med. 2015;372(23):2185–2196. doi: 10.1056/NEJMoa1503326.
    1. Wang X, Zhu G, Li D, Sheng J, Zhou X. Effect comparison between heated and humidified high-flow oxygen therapy with nasal catheter and non-invasive positive pressure ventilation in treating patients with acute type I respiratory failure. J Clin Med Pract. 2018;22(09):024.
    1. Zeng X, Zhang C, Le T, Jiang L, Wang X, Ye D, et al. Effects of high-flow nasal cannula oxygen therapy on arterial blood gas, respiratory mechanics and 28 days mortality rate in patients with severe type I respiratory failure. J Kunming Med Univ. 2019;40(12):80–85.
    1. Sterne JA, Sutton AJ, Ioannidis JP, Terrin N, Jones DR, Lau J, et al. Recommendations for examining and interpreting funnel plot asymmetry in meta-analyses of randomised controlled trials. BMJ. 2011;343:d4002. doi: 10.1136/bmj.d4002.
    1. van Valkenhoef G, Dias S, Ades AE, Welton NJ. Automated generation of node-splitting models for assessment of inconsistency in network meta-analysis. Res Synth Methods. 2016;7(1):80–93. doi: 10.1002/jrsm.1167.
    1. Nishimura M. High-flow nasal cannula oxygen therapy devices. Respir Care. 2019;64(6):735–742. doi: 10.4187/respcare.06718.
    1. Renda T, Corrado A, Iskandar G, Pelaia G, Abdalla K, Navalesi P. High-flow nasal oxygen therapy in intensive care and anaesthesia. Br J Anaesth. 2018;120(1):18–27. doi: 10.1016/j.bja.2017.11.010.
    1. Maggiore SM, Idone FA, Vaschetto R, Festa R, Cataldo A, Antonicelli F, et al. Nasal high-flow versus Venturi mask oxygen therapy after extubation. Effects on oxygenation, comfort, and clinical outcome. Am J Respir Crit Care Med. 2014;190(3):282–288. doi: 10.1164/rccm.201402-0364OC.
    1. Besnier E, Hobeika S, Nseir S, Lambiotte F, Du Cheyron D, Sauneuf B, et al. High-flow nasal cannula therapy: clinical practice in intensive care units. Ann Intensive Care. 2019;9(1):98. doi: 10.1186/s13613-019-0569-9.
    1. Walsh BK, Smallwood CD. Pediatric oxygen therapy: a review and update. Respir Care. 2017;62(6):645–661. doi: 10.4187/respcare.05245.
    1. He Y, Liu N, Zhuang X, Wang X, Ma W. High-flow nasal cannula versus noninvasive ventilation in patients with COVID-19: a systematic review and meta-analysis. Ther Adv Respir Dis. 2022;16:17534666221087847. doi: 10.1177/17534666221087847.
    1. Agarwal A, Basmaji J, Muttalib F, Granton D, Chaudhuri D, Chetan D, et al. High-flow nasal cannula for acute hypoxemic respiratory failure in patients with COVID-19: systematic reviews of effectiveness and its risks of aerosolization, dispersion, and infection transmission. Can J Anaesth. 2020;67(9):1217–1248. doi: 10.1007/s12630-020-01740-2.
    1. Rochwerg B, Granton D, Wang DX, Helviz Y, Einav S, Frat JP, et al. High flow nasal cannula compared with conventional oxygen therapy for acute hypoxemic respiratory failure: a systematic review and meta-analysis. Intensive Care Med. 2019;45(5):563–572.
    1. Frat JP, Coudroy R, Marjanovic N, Thille AW. High-flow nasal oxygen therapy and noninvasive ventilation in the management of acute hypoxemic respiratory failure. Ann Transl Med. 2017;5(14):297. doi: 10.21037/atm.2017.06.52.
    1. Mauri T, Turrini C, Eronia N, Grasselli G, Volta CA, Bellani G, et al. Physiologic effects of high-flow nasal cannula in acute hypoxemic respiratory failure. Am J Respir Crit Care Med. 2017;195(9):1207–1215. doi: 10.1164/rccm.201605-0916OC.
    1. Grieco DL, Menga LS, Eleuteri D, Antonelli M. Patient self-inflicted lung injury: implications for acute hypoxemic respiratory failure and ARDS patients on non-invasive support. Minerva Anestesiol. 2019;85(9):1014–1023. doi: 10.23736/S0375-9393.19.13418-9.
    1. Frat JP, Ragot S, Girault C, Perbet S, Prat G, Boulain T, et al. Effect of non-invasive oxygenation strategies in immunocompromised patients with severe acute respiratory failure: a post-hoc analysis of a randomised trial. Lancet Respir Med. 2016;4(8):646–652. doi: 10.1016/S2213-2600(16)30093-5.
    1. Cheng LC, Chang SP, Wang JJ, Hsiao SY, Lai CC, Chao CM. The impact of high-flow nasal cannula on the outcome of immunocompromised patients with acute respiratory failure: a systematic review and meta-analysis. Medicina (Kaunas) 2016;55(10):693. doi: 10.3390/medicina55100693.
    1. Basile MC, Mauri T, Spinelli E, Dalla Corte F, Montanari G, Marongiu I, et al. Nasal high flow higher than 60 L/min in patients with acute hypoxemic respiratory failure: a physiological study. Crit Care. 2020;24(1):654. doi: 10.1186/s13054-020-03344-0.
    1. Parke RL, Bloch A, McGuinness SP. Effect of very-high-flow nasal therapy on airway pressure and end-expiratory lung impedance in healthy volunteers. Respir Care. 2015;60(10):1397–1403. doi: 10.4187/respcare.04028.
    1. Roca O, Riera J, Torres F, Masclans JR. High-flow oxygen therapy in acute respiratory failure. Respir Care. 2010;55(4):408–413.
    1. Ritchie JE, Williams AB, Gerard C, Hockey H. Evaluation of a humidified nasal high-flow oxygen system, using oxygraphy, capnography and measurement of upper airway pressures. Anaesth Intensive Care. 2011;39(6):1103–1110. doi: 10.1177/0310057X1103900620.
    1. Zhang R, He H, Yun L, Zhou X, Wang X, Chi Y, et al. Effect of postextubation high-flow nasal cannula therapy on lung recruitment and overdistension in high-risk patient. Crit Care. 2020;24(1):82. doi: 10.1186/s13054-020-2809-7.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe