Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada.
Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.
Crit Care. 2022 Nov 9;26(1):348. doi: 10.1186/s13054-022-04218-3.
Non-invasive ventilation (NIV) with bi-level positive pressure ventilation is a first-line intervention for selected patients with acute hypercapnic respiratory failure. Compared to conventional oxygen therapy, NIV may reduce endotracheal intubation, death, and intensive care unit length of stay (LOS), but its use is often limited by patient tolerance and treatment failure. High-flow nasal cannula (HFNC) is a potential alternative treatment in this patient population and may be better tolerated.
For patients presenting with acute hypercapnic respiratory failure, is HFNC an effective alternative to NIV in reducing the need for intubation?
We searched EMBASE, MEDLINE, and the Cochrane library from database inception through to October 2021 for randomized clinical trials (RCT) of adults with acute hypercapnic respiratory failure assigned to receive HFNC or NIV. The Cochrane risk-of-bias tool for randomized trials was used to assess risk of bias. We calculated pooled relative risks (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with corresponding 95% confidence intervals (CI) using a random-effects model.
We included eight RCTs (n = 528) in the final analysis. The use of HFNC compared to NIV did not reduce the risk of our primary outcome of mortality (RR 0.86, 95% CI 0.48-1.56, low certainty), or our secondary outcomes including endotracheal intubation (RR 0.80, 95% CI 0.46-1.39, low certainty), or hospital LOS (MD - 0.82 days, 95% CI - 1.83-0.20, high certainty). There was no difference in change in partial pressure of carbon dioxide between groups (MD - 1.87 mmHg, 95% CI - 5.34-1.60, moderate certainty).
The current body of evidence is limited in determining whether HFNC may be either superior, inferior, or equivalent to NIV for patients with acute hypercapnic respiratory failure given imprecision and study heterogeneity. Further studies are needed to better understand the effect of HFNC on this population.
双水平正压通气的无创通气（NIV）是治疗急性高碳酸血症性呼吸衰竭患者的一线干预措施。与常规氧疗相比，NIV 可降低气管插管率、死亡率和重症监护病房住院时间（LOS），但由于患者耐受和治疗失败，其应用往往受到限制。高流量鼻导管（HFNC）是该患者人群的潜在替代治疗方法，可能更容易耐受。
对于急性高碳酸血症性呼吸衰竭患者，HFNC 是否是 NIV 减少插管需求的有效替代方法？
我们从数据库成立到 2021 年 10 月，通过 EMBASE、MEDLINE 和 Cochrane 图书馆搜索了接受 HFNC 或 NIV 治疗的急性高碳酸血症性呼吸衰竭成人的随机临床试验（RCT）。使用 Cochrane 随机试验偏倚风险工具评估偏倚风险。我们使用随机效应模型计算了二分类结局的汇总相对风险（RR）和连续结局的平均差异（MD），并计算了相应的 95%置信区间（CI）。
我们最终分析纳入了 8 项 RCT（n=528）。与 NIV 相比，HFNC 并未降低我们的主要结局死亡率的风险（RR 0.86，95%CI 0.48-1.56，低确定性），也未降低我们的次要结局包括气管插管率（RR 0.80，95%CI 0.46-1.39，低确定性）或住院 LOS（MD -0.82 天，95%CI -1.83-0.20，高确定性）。两组间二氧化碳分压的变化无差异（MD -1.87mmHg，95%CI -5.34-1.60，中等确定性）。
由于不精确和研究异质性，目前的证据有限，无法确定 HFNC 是否优于、劣于或等同于 NIV 治疗急性高碳酸血症性呼吸衰竭患者。需要进一步研究以更好地了解 HFNC 对这一人群的影响。
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