Comparison of initial oxygen therapy provided through high-flow nasal cannula versus noninvasive ventilation in patients with acute heart failure

Abstract

Background: Oxygen therapy with high-flow nasal cannula (HFNC) is being increasingly used in patients with acute heart failure (AHF), but its impact on short-term outcomes has been poorly reported. This study aims to compare short-term outcomes in patients with AHF and respiratory distress who received initial oxygen therapy with HFNC versus noninvasive ventilation (NIV) in the emergency department (ED).
Methods: In this retrospective analysis of prospectively collected data from a multicenter registry, we included all patients diagnosed with AHF in 35 Spanish EDs during January–February 2022 who received either HFNC or NIV as initial oxygen therapy. Patient allocation to initial HFNC or NIV was left to the discretion of the treating emergency physician. The primary outcome was 30-day all-cause mortality. Secondary outcomes included treatment failure (defined as the need for switch of oxygen therapy techniques or escalation to NIV to mechanical ventilation), intensive care unit admission, endotracheal intubation, in-hospital mortality, a composite endpoint of intubation or 7-day mortality, and prolonged hospitalization (>7 days). Associations were expressed as adjusted odds ratios (aOR) with 95% confidence intervals (CIs), using age, sex, and significant patient-and episode-related characteristics as covariates.
Results: Of 4301 patients with AHF, 330 (7.7%) were included (median age: 83 years; 57% women): 71 received HFNC and 259 received NIV. No statistically significant between-group differences were detected in the measured baseline characteristics; however, residual imbalance and unmeasured confounding cannot be excluded. A total of 66 (20.1%) patients died during 30-day follow-up with no significant difference between HFNC (21.4%) and NIV (19.8%) groups (aOR: 1.09; 95% CI: 0.55–2.17). HFNC was more frequently followed by a change or escalation in respiratory support (23.9% vs. 2.3%, aOR: 17.9; 95% CI: 5.90–54.2). This composite outcome was mainly driven by switches from HFNC to NIV (13/17 cases in the HFNC group) rather than by escalation to invasive mechanical ventilation, and should not be interpreted as direct evidence that HFNC was clinically inferior to NIV. But no significant differences were found for the other secondary endpoints.
Conclusion: In this analysis of patients with AHF treated in the ED, no statistically significant between-group difference in 30-day mortality was detected between initial HFNC and NIV. However, given the wide confidence intervals, these findings do not establish equivalence. Larger randomized trials are warranted to confirm the comparative effectiveness of these two oxygenation strategies.

Keywords

Acute heart failure / Emergency department / High-flow nasal cannula / Noninvasive ventilation

References

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