High-Flow Nasal Cannula Versus Noninvasive Ventilation for Prevention of Reintubation in High-Risk Critically Ill Patients (HIGH-FLOW OXY): An Informative Systematic Review and Meta-Analysis.

Optimal postextubation respiratory support for critically ill patients at high risk of reintubation remains uncertain. We aimed to compare the efficacy of high-flow nasal cannula (HFNC) vs. noninvasive ventilation (NIV) in preventing reintubation among critically ill adults at high risk of extubation failure. PubMed, Cochrane Central Register of Controlled Trials, Embase, and ClinicalTrials.gov were systematically searched from inception through the latest available date. HIGH-FLOW OXY is a systematic review and meta-analysis comparing HFNC with NIV in ICU patients at high risk of extubation failure. The primary outcome was short-term reintubation within 3 days postextubation. Secondary outcomes included ICU mortality, ICU length of stay, sepsis, and nosocomial pneumonia. Data were extracted using predefined criteria. Risk of bias (RoB) was assessed with the Cochrane tool, and certainty of evidence was evaluated using Grading of Recommendations, Assessment, Development, and Evaluation. Random-effects models were used for pooled analyses. Prespecified subgroup analyses included obese patients, very high-risk patients, elderly individuals, and those with acute exacerbations of chronic obstructive pulmonary disease. Fifteen randomized controlled trials (RCTs; n = 2073) were included. HFNC and NIV did not differ significantly in reintubation (odds ratio [OR], 1.19; 95% CI, 0.88-1.59), ICU mortality (OR, 0.74; 95% CI, 0.40-1.38), sepsis (OR, 1.29; 95% CI, 0.71-2.35), nosocomial pneumonia (OR, 1.01; 95% CI, 0.67-1.52), or ICU length of stay (MD -0.37 d; 95% CI, -1.42 to 0.68). Subgroup analyses suggested a higher reintubation risk with HFNC among very high-risk patients (OR, 1.63; 95% CI, 1.05-2.53) and nonoperative obese patients (OR, 2.52; 95% CI, 1.45-4.38). Sensitivity analysis excluding trials at high RoB indicated a potential increase in reintubation with HFNC (OR, 1.32; 95% CI, 1.02-1.71). Overall, certainty of evidence was low across outcomes. Among ICU patients at high risk of extubation failure, HFNC did not reduce reintubation compared with NIV, and may be associated with increased risk in selected high-risk subgroups. Further adequately powered, risk-stratified RCTs are warranted to define the optimal postextubation respiratory support strategy.