Am J Emerg Med. 2025 Sep 19;100:124-132. doi: 10.1016/j.ajem.2025.09.036. Online ahead of print.
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.
PubMed:41344140 | DOI:10.1016/j.ajem.2025.09.036