Author(s)

Fujing Yang ¹, Yunchuan Zhong ¹, Qiuyan Yu ¹

Affiliation(s)

¹ Department of Emergency, First People's Hospital of Neijiang, Neijiang, China

Corresponding Author

Qiuyan Yu

ABSTRACT

Previous meta-analyses of noninvasive respiratory support for acute hypoxemic respiratory failure (AHRF) have often treated noninvasive ventilation (NIV) as a single intervention and have pooled non-comparable intubation outcomes. We updated the randomized evidence base and reassessed comparative effectiveness after harmonizing standalone intubation endpoints and separating NIV according to interface and ventilation mode. Embase, PubMed, the Cochrane Library, and Web of Science were searched from inception to March 7, 2026 for randomized controlled trials in adults with AHRF. The primary outcome was short-term standalone endotracheal intubation reported during the index hospitalization or by day 28-30; composite endpoints, including intubation-or-death, were excluded from the primary efficacy network. Thirty-seven randomized trials involving 6,592 participants were retained in the evidence base, and 28 trials involving 5,583 participants informed the primary endpoint-harmonized network. Compared with standard oxygen therapy (SOT), short-term standalone intubation was reduced with helmet NIV (odds ratio [OR] 0.20, 95% credible interval [CrI] 0.09-0.43), high-flow nasal cannula (HFNC; OR 0.54, 95% CrI 0.34-0.80), and face-mask NIV (OR 0.56, 95% CrI 0.37-0.79). In the prespecified 6-node network, helmet bilevel NIV showed the largest estimated effect versus SOT (OR 0.12, 95% CrI 0.05-0.29). Restriction to strict day-28/day-30 standalone intubation attenuated effect sizes but did not change the direction of effect. No active strategy was associated with a credible reduction in day-28/day-30 mortality. In adults with AHRF, HFNC, face-mask NIV, and helmet NIV each reduced short-term standalone intubation compared with SOT after endpoint harmonization; the apparent helmet benefit was driven mainly by helmet bilevel NIV. Mortality data remain too sparse for firm comparative conclusions. 

KEYWORDS

Acute hypoxemic respiratory failure; High-flow nasal cannula; Noninvasive ventilation; Helmet NIV; Bayesian network meta-analysis; Endotracheal intubation

CITE THIS PAPER

Fujing Yang, Yunchuan Zhong, Qiuyan Yu. High-flow nasal cannula and interface- or mode-specific noninvasive ventilation in acute hypoxemic respiratory failure: an endpoint-harmonized systematic review and Bayesian network meta-analysis of randomized trials. MEDS Clinical Medicine (2026). Vol. 7, No.2, 51-60. DOI: http://dx.doi.org/10.23977/medsc.2026.070208.

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