High-flow nasal cannula versus noninvasive ventilation in acute heart failure-related respiratory failure: a systematic review and meta-analysis
Abstract
Background: Noninvasive ventilation (NIV) is the recommended first-line respiratory support for acute heart failure (AHF)-related respiratory failure. However, its tolerance is often limited. High-flow nasal cannula (HFNC) has emerged as a potential alternative, but comparative evidence remains inconsistent. This study aimed to evaluate the efficacy and safety of HFNC versus NIV in patients with AHF-related respiratory failure.
Methods: We conducted a systematic review and meta-analysis following PRISMA guidelines. We searched four major electronic databases from inception to April 2026. We included randomized controlled trials (RCTs) and observational studies enrolling adult patients with respiratory failure secondary to AHF or acute cardiogenic pulmonary edema, comparing HFNC and NIV. The primary outcome was composite treatment failure. Secondary outcomes included endotracheal intubation, short-term mortality, arterial blood gas (ABG) parameters, respiratory rate, dyspnea scores, and hospital length of stay. A random-effects model was used. The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.
Results: Ten studies (n = 1,282 patients) were included, comprising five RCTs and five observational studies. HFNC showed no statistically significant difference compared with NIV in the composite outcome of treatment failure (RR = 1.22, 95% CI: 0.81-1.84), endotracheal intubation (RR = 0.86, 95% CI:…
How strong is the evidence?
Evidence Hub reads this as a meta-analysis, done in people. Its evidence level is 1 of 5 (Highest · pooled evidence). Pooled evidence from several studies sits at the top of the evidence pyramid. Reported size: 1,282 participants or records.
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