The efficacy of high-flow nasal cannula versus non-invasive mechanical ventilation in preventing reintubation in patients at high risk of extubation failure: systematic review and meta-analysis with trial sequential analysis

OBJECTIVE: To conduct a systematic review and meta-analysis with trial sequential analysis to compare the efficacy of high-flow nasal cannula versus noninvasive ventilation in preventing reintubation, post-extubation respiratory failure, mortality, and length of stay in intensive care unit and hospital in patients at high risk of extubation failure. METHODS: A comprehensive literature search was conducted across ten databases: MEDLINE®/PubMed®, Web of Science, SciELO, Embase, Scopus, the Cochrane Central Register of Controlled Trials, the International Clinical Trials Registry Platform, Google Scholar, GreyNet International, and OpenGrey. The primary outcome was reintubation. Secondary outcomes included post-extubation respiratory failure, intensive care unit and hospital mortality, as well as intensive care unit and hospital length of stay. RESULTS: Ten randomized controlled trials comprising 1,697 patients were included. There were no significant differences between high-flow nasal cannula and non-invasive ventilation in reintubation (RR = 1.00; 95%CI 0.92 - 1.09; p = 0.92; I2 = 65.0%), intensive care unit mortality (RR 1.03; 95%CI 1.00 - 1.07; p = 0.08; I2 = 28.0%), hospital mortality (RR 1.02; 95%CI 0.99 - 1.06; p = 0.13; I2 = 0%), intensive care unit length of stay (mean difference: -0.51 days; 95%CI -1.85 to 0.82; I2 = 63.0%), and hospital length of stay (mean difference: 0.80 days; 95%CI -1.72 to 3.32; I2 = 47.0%). High-flow nasal cannula showed a non-significant trend toward lower post-extubation respiratory failure and intensive care unit mortality in patients ventilated > 5 days. CONCLUSION: In adult patients at high risk of extubation failure, the use of high-flow nasal cannula is not associated with significant differences in reintubation rates, intensive care unit or hospital mortality, or intensive care unit or hospital length of stay compared with noninvasive ventilation.PROSPERO register: CRD420251104362.