Clinical question: Is high-flow nasal cannula oxygen therapy (HFNC) non-inferior to non-invasive ventilation (NIV) for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) in patients admitted to the medical intensive care unit?
Background: NIV is the recommended standard respiratory therapy for patients who present with AECOPD and moderate hypercapnic respiratory failure. Cumulative studies have shown benefits in using HFNC for stable COPD patients; however, randomized trials comparing HFNC with NIV for the initial treatment of AECOPD are limited.
Study design: Randomized, open-label, non-inferiority trial
Setting: Two intensive care units at a large tertiary academic teaching hospital in China between March 2018 and December 2022
Synopsis: 228 patients admitted to two intensive care units for AECOPD who had baseline arterial blood gas pH between 7.25 and 7.35 and PaCO2 of at least 50 mmHg were randomized to receive initial respiratory support with HFNC or NIV. The primary endpoint was the failure rate of the initial intervention (either via intubation or a switch to the other study treatment modality). The failure rate of the HFNC group was higher (25.7%) than the NIV group (14.3%). The HFNC group also experienced higher intubation rates compared to the NIV group (14.2% versus 5.4%, P=0.026). The failure rate risk difference between both groups was 11.38% (95% CI, 0.25-21.20, P=0.033), which was higher than the 9% cutoff for non-inferiority. Some study limitations included generalizability, given it was a single-center study, and the inability to blind the attending physicians or patients to the intervention. The study demonstrated that HFNC resulted in more intubations or switches to the other study treatment modality, compared to NIV use, when used as initial respiratory support for patients with AECOPD and moderate hypercapnic respiratory failure.
Bottom line: Initial respiratory support with HFNC resulted in more frequent treatment failure and intubations compared to NIV in patients presenting with acute to moderate hypercapnic respiratory failure from AECOPD.
Citation: Tan D, et al. High flow nasal cannula oxygen therapy versus non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease with acute-moderate hypercapnic respiratory failure: a randomized controlled non-inferiority trial. Crit Care. 2024;28(1):250. doi:10.1186/s13054-024-05040-9
Dr. Boctor is an academic hospitalist in the department of internal medicine and an assistant clinical professor at the University of California Davis School of Medicine, and an executive board member for SHM’s Sacramento chapter, both in Sacramento, Calif.