High-flow Nasal Therapy vs Noninvasive Ventilation for Post-extubation Patients at High Risk of Reintubation: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND: Current guidelines recommend noninvasive ventilation (NIV) over high-flow nasal cannula (HFNC) in patients at high risk of extubation failure. This systematic review and meta-analysis aimed to compare the efficacy of HFNC vs NIV in post-extubation patients at high risk of reintubation. METHODS: A systematic search was conducted in PubMed, Embase, Cochrane Library, and ClinicalTrials.gov without language restrictions. Randomized controlled trials (RCTs) evaluating HFNC vs NIV in post-extubation patients were included. The primary outcome was reintubation within 72h. Effect estimates were pooled as risk ratios (RR) with 95%CI. Certainty of evidence was assessed using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) framework and categorized as high, moderate, low, or very low. RESULTS: Eleven RCTs (n=2765 patients) met inclusion criteria. No statistically significant differences were observed between HFNC and NIV for reintubation within 72h (RR, 1.22; 95%CI, 0.83-1.80; moderate), reintubation within 7 days (RR, 1.23; 95%CI, 0.90-1.69; low), post-extubation respiratory failure (RR, 0.82; 95%CI, 0.66-1.02; moderate), intensive care unit (ICU) mortality (RR, 0.90; 95%CI, 0.63-1.29; very low), in-hospital mortality (RR, 0.96; 95%CI, 0.74-1.25; moderate), or 28-day mortality (RR, 0.99; 95%CI, 0.59-1.65; moderate). CONCLUSIONS: Compared with NIV, HFNC was not associated with increased reintubation or mortality. However, variability in study definitions may limit direct applicability to bedside decision-making in individual high-risk patients.