High-Flow Nasal Therapy vs NIV in Acute COPD Exacerbation With Hypercapnia: A Meta-Analysis of RCTs

Introduction: Noninvasive ventilation (NIV) is the standard of care for acute hypercapnic respiratory failure (AHRF) in patients with acute exacerbation of COPD (AECOPD). High-flow nasal therapy (HFNT) has emerged as a potential alternative. We conducted a meta-analysis of randomized controlled trials (RCTs) to compare the efficacy of HFNT versus NIV as initial respiratory support in this population.


Methods: We systematically searched PubMed, Embase, MEDLINE, Cochrane CENTRAL, and ClinicalTrials.gov for RCTs comparing HFNT and NIV in AECOPD patients with AHRF. Outcomes included mortality, treatment failure, intubation rates, hospital length of stay, and patient satisfaction. A random-effects model was used for pooled analyses. Heterogeneity was assessed using the I² statistic.


Results: Nine RCTs comprising 979 patients were included. NIV significantly reduced treatment failure compared to HFNT (OR 1.83; 95% CI 1.25–2.67; p=0.008). HFNT was associated with shorter hospital stays (MD –0.92 days; 95% CI –1.59 to –0.25; p=0.02) and higher patient satisfaction. No significant differences were observed in overall mortality (OR 0.84; p=0.67), 28-day mortality (OR 1.09; p=0.73), or intubation rates (OR 1.16; p=0.55).


Conclusions: HFNT may be considered as an alternative to NIV in selected patients with AECOPD and AHRF, particularly those who are NIV-intolerant. While NIV remains superior in preventing treatment failure, HFNT offers advantages in comfort and length of stay. Further large-scale trials with longer follow-up are warranted to confirm these findings.