Home Noninvasive Ventilation vs High-Flow Nasal Cannula in COPD with Chronic Hypercapnic Respiratory Failure: A Network Meta-Analysis

Abstract

Introduction: Chronic hypercapnic respiratory failure (CHRF) in COPD increases mortality and hospitalizations. Home noninvasive ventilation (NIV) and high-flow nasal cannula (HFNC) are both used, but comparative efficacy is uncertain. This network meta-analysis (NMA) ranks these interventions.
Methods: NMA of RCTs (≥3 months) in COPD patients with daytime PaCO2 ≥50 mmHg. Interventions: NIV (any mode), HFNC, or standard oxygen. Primary outcomes: all-cause mortality and number of exacerbations. Searched up to May 2024.
Results: Fifteen RCTs (n=2,804) included. NIV reduced mortality compared to standard oxygen (OR 0.65, 95% CI 0.48–0.88); HFNC showed a non-significant reduction (OR 0.82, 0.60–1.12). For exacerbation frequency, NIV ranked first (rate ratio 0.68, 0.55–0.84), HFNC second (0.81, 0.65–1.01). NIV with high inspiratory pressure (>20 cmH2O) and backup rate had greatest benefit. HFNC improved nocturnal transcutaneous CO2 but less than NIV (mean difference -6 vs -12 mmHg).
Discussion: NIV remains superior, likely via rest of respiratory muscles and increased tidal volume. HFNC may benefit patients intolerant of NIV but should not replace it first-line. Limitations: most trials excluded obesity hypoventilation syndrome.
Conclusions: Home NIV, particularly high-pressure settings, is the preferred intervention for COPD-CHRF. HFNC is a second-line alternative.