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Peer-reviewedCC BY-NC 4.0BMJ Open Respiratory Research

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

  • Paraschos Archontakis Barakakis1,2
  • Milind Sovani3,4
  • Rahul Eric3
  • Midhina Ravikumar3
  • Jaikirat Singh Gugnani3
  • Chii Haw Hon5
  • Nilakantha Sumanam3
  • Georgios Mavrovounis6
  • Ioannis Pantazopoulos6,7
7 affiliations
  1. 1Hospital Medicine, Beverly Hospital, Beverly, Massachusetts, USA
  2. 2Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
  3. 3Respiratory Medicine, Queen’s Medical Centre, Nottingham, Nottingham, UK
  4. 4University of Derby, Derby, England, UK
  5. 5Respiratory Medicine, United Lincolnshire Hospitals NHS Trust, Lincoln, England, UK
  6. 6University of Thessaly School of Health Sciences, Larissa, Greece
  7. 7Department of Emergency Medicine, University of Thessaly Faculty of Medicine, Larissa, Greece
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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.

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Cite

BibTeXRIS
BibTeX
@article{barakakis2026highflow,
  title = {{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}},
  author = {Paraschos Archontakis Barakakis and Milind Sovani and Rahul Eric and Midhina Ravikumar and Jaikirat Singh Gugnani and Chii Haw Hon and Nilakantha Sumanam and Georgios Mavrovounis and Ioannis Pantazopoulos},
  journal = {BMJ Open Respiratory Research},
  year = {2026},
  month = nov,
  doi = {10.1136/bmjresp-2026-004442},
  url = {https://doi.org/10.1136/bmjresp-2026-004442},
  note = {CC BY-NC 4.0},
}
RIS
TY  - JOUR
TI  - 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
AU  - Paraschos Archontakis Barakakis
AU  - Milind Sovani
AU  - Rahul Eric
AU  - Midhina Ravikumar
AU  - Jaikirat Singh Gugnani
AU  - Chii Haw Hon
AU  - Nilakantha Sumanam
AU  - Georgios Mavrovounis
AU  - Ioannis Pantazopoulos
PY  - 2026
DA  - 2026/11/02
JO  - BMJ Open Respiratory Research
DO  - 10.1136/bmjresp-2026-004442
UR  - https://doi.org/10.1136/bmjresp-2026-004442
AB  - 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.
SN  - 2052-4439
ER  -