Work

High-flow nasal oxygen versus non-invasive ventilation in patients with acute hypercapnic exacerbation of COPD: a systematic review and meta-analysis of randomised controlled trials

Year: 2026

Type: review

Study designs: Systematic Review, Meta-Analysis

Abstract: Background Acute exacerbations of chronic obstructive pulmonary disease complicated by acute hypercapnia require respiratory support. Respiratory acidosis requires support that is often provided with high-flow nasal oxygen (HFNO) or non-invasive ventilation (NIV). Our aim is to compare the efficacy and safety of the two modalities.Methods We conducted a systematic review and meta-analysis of randomised controlled trials including patients with acute hypercapnia and respiratory acidosis following PRISMA guidelines. Searches were performed on PubMed, Scopus and Web of Science. The primary outcome was intubation/invasive mechanical ventilation. Secondary outcomes included mortality types, crossover to the other support modality, length of stay, physiological parameters and adverse events. Pooled estimates from random effects models (inverse-variance weights and DerSimonian-Laird estimator) were expressed as risk ratios (RR) or mean differences (MD) with 95% CI.Results Ten trials were included. The risk of intubation was similar between HFNO and NIV (RR 1.25, 95% CI 0.83 to 1.90). Crossover from HFNO to NIV was more frequent (RR 2.18, 95% CI 1.07 to 4.41). Mortality outcomes (28–30 day mortality: RR 1.11, 95% CI 0.66 to 1.89, hospital: RR 0.49, 95% CI 0.16 to 1.49) did not differ. Low-certainty evidence suggested a shorter length of stay with HFNO (MD –0.79 days, 95% CI –1.41 to –0.18).Conclusions No statistically significant differences were found between HFNO and NIV for intubation and mortality for patients with acute exacerbation of chronic obstructive pulmonary disease and respiratory acidosis. Provided crossover to the other therapy was allowed, more patients crossed over from HFNO to NIV. HFNO was associated with shorter LOS.

Source: BMJ Open Respiratory Research

DOI: 10.1136/bmjresp-2026-004442