High-Flow Nasal Oxygen Versus Conventional Oxygen Therapy and Non-Invasive Ventilation for Acute Respiratory Failure in the Emergency Department: A Systematic Review and Meta-Analysis
In brief
High-flow oxygen reduced intubations 36% across emergency respiratory-failure trials
In 17 trials involving 1,955 adults, high-flow nasal oxygen was associated with 36% fewer intubations than conventional oxygen and noninvasive ventilation combined. The reduction was clear versus conventional oxygen, but not versus noninvasive ventilation; results also varied by cause of respiratory failure, and concerns about bias and study differences limit confidence in the overall estimate.
- Journal
- Emergency medicine Australasia : EMA (Q1)
- Published
- 1 October 2026
- Study design
- Systematic review / meta-analysis of RCTs
- Evidence level
- Level 1, High (CEBM 1a)
- Authors
- Rupert Phillips, Adrianna Klejnotowska, Harry Claxton, Matthew Cadd
- PMID
- 42728228
- DOI
- 10.1111/1742-6723.70350
Why clinicians should know about it
- Picked for Critical Care and Intensive Care Medicine (paper of the day, 13 September 2026): HFNO reduces intubation, relevant for ARDS/ventilation strategy
- Picked for Emergency Medicine (paper of the day, 13 September 2026): HFNO reduces intubation in acute respiratory failure in ED
- Picked for Pulmonary and Respiratory Medicine (top studies of the week, 13 September 2026): Meta-analysis shows HFNO reduces intubation vs COT/NIV
Abstract
This systematic review and meta-analysis compares the use of high-flow nasal oxygen (HFNO) with conventional oxygen therapy (COT) and non-invasive ventilation (NIV) in the management of acute respiratory failure (ARF) in the emergency department (ED). A comprehensive search of relevant sources was undertaken. Randomised controlled trials (RCTs) assessing adult patients (≥ 18 years) treated in the ED for ARF and comparing HFNO to COT/NIV were included. The primary outcome was the need for endotracheal intubation and mechanical ventilation (IMV). Secondary outcomes included physiological and biochemical parameters, ICU admission, hospital length of stay, dyspnoea scores and mortality. A total of 17 RCTs (1955 patients) were included. There was a significant reduction in IMV favouring the HFNO group compared to COT and NIV (RR 0.64, 95% CI 0.47-0.88). HFNO showed significant improvements in RR, SpO2, PaO2 and Modified Borg Dyspnoea Scale. Subgroup analysis showed reduced rates of IMV with HFNO compared to COT (RR 0.61, 95% CI 0.41-0.91), but not compared to NIV (RR 0.69, 95% CI 0.42-1.14). HFNO additionally showed a reduction of IMV compared to NIV and COT in undifferentiated patients (RR 0.61, 95% CI 0.41-0.93), but not in exacerbations of COPD or acute heart failure. Ten of the 17 studies had at least some concern for risk of bias, with several analyses having notable heterogeneity. HFNO showed a significant reduction in rates of IMV, improvement in peripheral oxygen saturations, PaO2, respiratory rate and patient dyspnoea scores compared to COT and NIV.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.