Effectiveness and Harms of High-Flow Nasal Oxygen for Acute Respiratory Failure: An evidence report for a clinical guideline from the american college of physicians

Research output: Contribution to journalReview articlepeer-review

13 Scopus citations


BACKGROUND: Use of high-flow nasal oxygen (HFNO) for treatment of adults with acute respiratory failure (ARF) has increased. PURPOSE: To assess HFNO versus noninvasive ventilation (NIV) or conventional oxygen therapy (COT) for ARF in hospitalized adults. DATA SOURCES: English-language searches of MEDLINE, Embase, CINAHL, and Cochrane Library from January 2000 to July 2020; systematic review reference lists. STUDY SELECTION: 29 randomized controlled trials evaluated HFNO versus NIV (k = 11) or COT (k = 21). DATA EXTRACTION: Data extraction by a single investigator was verified by a second, 2 investigators assessed risk of bias, and evidence certainty was determined by consensus. DATA SYNTHESIS: Results are reported separately for HFNO versus NIV, for HFNO versus COT, and by initial or postextubation management. Compared with NIV, HFNO may reduce all-cause mortality, intubation, and hospital-acquired pneumonia and improve patient comfort in initial ARF management (low-certainty evidence) but not in postextubation management. Compared with COT, HFNO may reduce reintubation and improve patient comfort in postextubation ARF management (low-certainty evidence). LIMITATIONS: Trials varied in populations enrolled, ARF causes, and treatment protocols. Trial design, sample size, duration of treatment and follow-up, and results reporting were often insufficient to adequately assess many outcomes. Protocols, clinician and health system training, cost, and resource use were poorly characterized. CONCLUSION: Compared with NIV, HFNO as initial ARF management may improve several clinical outcomes. Compared with COT, HFNO as postextubation management may reduce reintubations and improve patient comfort; HFNO resulted in fewer harms than NIV or COT. Broad applicability, including required clinician and health system experience and resource use, is not well known. PRIMARY FUNDING SOURCE: American College of Physicians. (PROSPERO: CRD42019146691).

Original languageEnglish (US)
Pages (from-to)952-966
Number of pages15
JournalAnnals of internal medicine
Issue number7
StatePublished - Jul 1 2021

Bibliographical note

Funding Information:
This review was funded by a contract with ACP. An ACP representative provided technical support and served as a liaison with the ACP CGC and technical expert panel. The ACP CGC assisted in the development of key questions, study inclusion criteria, and outcome measures of interest but did not participate in data collection, analysis, or manuscript preparation.

Publisher Copyright:
© 2021 American College of Physicians. All rights reserved.


  • Acute Disease
  • Adult
  • Cause of Death
  • Continuous Positive Airway Pressure
  • Critical Care
  • Dyspnea/etiology
  • Healthcare-Associated Pneumonia
  • Hospital Mortality
  • Humans
  • Intermittent Positive-Pressure Ventilation
  • Intubation, Intratracheal
  • Length of Stay
  • Noninvasive Ventilation/methods
  • Outcome Assessment, Health Care
  • Oxygen Inhalation Therapy/methods
  • Prospective Studies
  • Respiratory Insufficiency/complications
  • United States

PubMed: MeSH publication types

  • Review
  • Research Support, Non-U.S. Gov't
  • Journal Article
  • Research Support, N.I.H., Extramural


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