Ahmad Saad Alomari et al, 2024;8(1):438–443.

International Journal of Medicine in Developing Countries

https://doi.org/10.24911/IJMDC.51-1701160145

REVIEW ARTICLE

Noninvasive ventilation strategy for patients

with acute respiratory failure in emergency
department - a systematic review
Ahmad Saad Alomari1, Sultan Ibrahim Abu Tayli2, Abdulaziz Mohammed M.
Alzaydan3* , Rayan Bin Abdulrahman Bin Muneef3, Turki Ibrahim Aljaber4,
Renad Bader A. Alsekait4, Shahd Abdulaziz Alabdulathim5, Shoog Khalid
Aloleeit5, Wedad Saad Aldhahry6, Wasn Turki Alotaibi7

ABSTRACT
Background: We sought to assess the efficacy of noninvasive positive pressure ventilation against high-flow
nasal cannula in patients experiencing acute respiratory failure, as they may be necessary if the respiratory
insufficiency is more severe.
Method: We conducted a thorough search from 2013 to 2023 throughout Embase, Cochrane Library, MEDLINE,
and CINAHL databases. We incorporated randomized control trials that contrasted adult patients with acute
respiratory failure with high flow nasal cannula (HFNC) and nasal intermittent positive pressure ventila-
tion (NIPPV) We collected data on trial features, demographics, intervention and control arm management,
and clinical outcome outcomes of interest. For the economic outcomes, we collected data on the analytical
approach, research design, time horizon, study viewpoint, and study features.
Results: We included 6 randomized controlled trials (RCTs) with a total of 1,421 patients after evaluating 612
citations. Patients in RCTs ranged in number from 30 to 791. Of the six RCTs, one was published after being
abstracted. Overall, HFNC was compared to facemask NIPPV in five investigations, and to both facemasks in
one research. Patients with hypoxic respiratory failure caused by the corona virus were included in two inves-
tigations, along with those with mixed hypoxia respiratory failure, immunocompromised patients by them-
selves, and one study with mixed respiratory failure.
Conclusion: While there is conflicting evidence about the impact of HFNC and NIPPV on mortality in hospital-
ized patients with hypoxemic respiratory failure, they may be equally successful in lowering the requirement
for intubation.
Keywords: Noninvasive, acute respiratory failure, emergency department.

Introduction

Acute respiratory failure patients get oxygen
treatment via a range of techniques. A Venturi mask
or nasal cannula used to administer low-flow oxygen
treatment may be appropriate for those who are less
hypoxemic. A high-flow nasal cannula or noninvasive
positive pressure ventilation may be required if the
respiratory insufficiency is more severe. Hard plastic
nasal cannulas may supply oxygen at flow rates of
40-60 l/minute with high flow nasal cannula (HFNC),
more closely meeting the inspiratory requirements of
dyspneic patients [1].
In addition, HFNC can reduce nasopharyngeal
resistance and pharyngeal dead space in addition to
Correspondence to: Abdulaziz Mohammed M. Alzaydan
*General Physician, College of Medicine, King Saud
University, Riyadh, Saudi Arabia.
Email: azizalzaydan@gmail.com
Full list of author information is available at the end of
this article.
Received: 28 November 2023 | Accepted: 14 December 2023

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 Noninvasive ventilation acute respiratory failure
providing a mild positive end-expiratory pressure
of 7 cm H2O, depending on mouth opening [2,3]. In
addition, College of Medicine, HFNC could be less
intrusive and more pleasant for patients than other
methods of oxygen administration [2].
Positive pressure ventilation via a face mask is provided
by nasal intermittent positive pressure ventilation
(NIPPV) an additional modality utilized in patients with
severe respiratory failure [4]. As a result, positive end-
expiratory pressure may be administered titratably, and
tidal volumes can be increased in response to inspiration
initiated by the patient. Compared to HFNC, NIPPV
frequently requires more monitoring and is not as well
tolerated [5]. While NIPPV may be a better treatment
for some situations, such as hypercapnic respiratory
failure, the best way to administer oxygen to patients
with severe acute heart failure is still up for debate [6].
Although guidelines assessing NIPPV and HFNC are
available, they often concentrate on comparing these two
modalities to routine low-flow oxygen treatment rather
than comparing them to each other [7,8]. Given that
HFNC involves less setup, monitoring, and maintenance
Figure 1. Selection flow chart.
439
than NIPPV and is less resource-intensive overall, there
may be advantages when it comes to prudent healthcare
resource use [6]. This review’s main inquiry compares
HFNC with NIPPV, assessing their respective efficacies
and financial viability in acute respiratory failure (ARF)
patients.
Method
We conducted a systematic review search from 2013
to 2023 throughout MEDLINE, Embase, CINAHL,
the Cochrane Library, and the International Health
Technology Assessment database. We searched using
keywords including the primary terms HFNC, NIPPV,
and acute hypoxemic respiratory failure. We limited our
search to articles written in English.
After utilizing Mendeley software to eliminate duplicates,
we conducted the investigations in two phases: initially,
we looked at the abstracts and titles, and then we looked
at the complete text of a few chosen citations. After
examining the whole texts of the identified trials, we
recorded the grounds for study exclusion in Figure 1.
 Noninvasive ventilation acute respiratory failure
Studies that examined at least one of the following
outcomes of interest - need for intubation, mortality,
length of stay in the intensive care unit, length of stay in
the hospital, or patient comfort - and compared HFNC
to NIPPV in adult patients (>18 years) hospitalized
with AHRF were included in our analysis. Any device
that provides mechanical respiratory support through
an interface that provides bilevel or continuous positive
airway support (CPAP) without requiring endotracheal
intubation is considered noninvasive positive pressure
ventilation, or NIPPV.
We gathered information on trial characteristics,
demographics, management of the intervention and
control arms, and outcomes of interest for the clinical
outcomes. We gathered information on the analytical
method, study design, time horizon, study perspective,
and study characteristics for the economic outcomes.
Three of the study authors completed the preliminary
screening to clear out duplicates and irrelevant
publications. Potential articles were then chosen again
after a more careful assessment of their abstracts and
titles. At this stage, a sample of the research was assessed
by each reviewer to ensure consistency and identify any
instances in which the selection criteria were imprecise
or confusing. Following this screening, the studies’
complete texts that were still available were collected,
and they were carefully assessed in comparison to the
criteria. Each full-text manuscript was assessed by
all reviewers. Disagreements were resolved through
discussion in order to bring all reviewers to a consensus.
From each included study, we extracted the following
data: author, publication year, findings, country, sample
size, and outcomes.
Results
After analyzing 612 citations, we included 6 randomized
controlled trials (RCTs) [9-14], totaling 1,421 patients
(Figure 1). Table 1 shows the features of the RCTs that
were included. RCTs had a range of patients from 30 to
791. One of the six RCTs was abstracted and published
[10]. In all, five studies [9-11,13,14] compared HFNC to
facemask NIPPV, while one study compared it to both
facemasks [12].
Two studies included individuals with corona virus
hypoxic respiratory failure [12,14], two included
mixed hypoxia respiratory failure [10,11], one included
immunocompromised individuals alone [13], and one
mixed respiratory failure [9]. The studies were conducted
in six different countries; Brazil [10], the USA [9], Egypt
[13], France [11], India [12], and the UK [14].
According to Azevedo et al. [10], the necessity for
invasive ventilation and endotracheal intubation was not
significantly different in hypoxemic respiratory failure
patients under HFNC and NIPPV management. Frat et
al. [11] study found that the rate of intubations in patients
with nonhypercapnic acute hypoxemic respiratory failure
did not vary substantially whether high-flow oxygen,
440
conventional oxygen, or noninvasive ventilation was
used as treatment. While Doshi et al. [9] declared that
in emergency department patients with undifferentiated
respiratory failure, high-velocity nasal insufflation is
better if compared to noninvasive positive-pressure
ventilation. On the other hand, Nair et al. [12] found
that neither the intubation rate nor the oxygenation
parameters improved statistically significantly between
HFNC and non-invasive ventilation (NIV) after 48 hours.
Regarding immunocompromised patients with ARF, the
use of a high-flow nasal cannula reduces the incidence of
endotracheal intubation [13]. In individuals with corona
virus, when compared to conventional oxygen therapy
(COT), an initial CPAP strategy decreased the incidence
of tracheal intubation (Table 2).
Discussion
In comparison to NIPPV, HFNC probably had no
influence on the requirement for intubation and a dubious
effect on death. A subgroup study suggests that NIPPV
administered through the helmet interface, as opposed
to the facemask interface, may lower intubation rates as
compared to HFNC. Regarding other results, the duration
of hospital or intensive care unit stays probably did not
change, and the impact on patient-reported dyspnea was
insignificant. Regarding the cost-effectiveness of HFNC
in comparison to NIPPV, no conclusion could be drawn.
Although this research topic has been the subject of prior
systematic reviews [15], this is the first review carried
out in the wake of one sizable RCT that was published in
2021 [14]. The primary outcome of respiratory support
free days was not different between helmet NIPPV and
HFNC in the HENIVOT study [14]; however, there was
a noteworthy decrease in intubation rates with helmet
NIPPV. It should be noted that HENIVOT lacked the
necessary power for intubation; as a result, the data
lacked precision, which weakened the conclusions.
RECOVERY-RS, the second recent RCT, was a three-
arm experiment that contrasted COT with HFNC and
NIPPV [14].
Even though there was no difference between NIPPV
and HFNC when compared to COT in the major
composite outcome of tracheal intubation and death, it is
crucial to remember that this trial featured a significant
number of crossover cases. In addition, rather than
using bilevel ventilation with pressure assistance,
NIPPV in RECOVERY was limited to CPAP. Because
most doctors employ facemasks or helmet interfaces
for bilevel ventilation, this may have limited the data’s
generalizability. When combined with other RCTs, the
apparent benefits of NIPPV versus HFNC from these
two more recent RCTs are lessened. As a result, drawing
a judgment about whether one mode is more beneficial
than another is still difficult.
When comparing NIPPV to HFNC for the result of
intubation, a plausible subgroup effect was seen, taking
into account the various modalities of NIPPV in this
 Table 1. Characteristics of the included studies.
Citation Settings for NIPPV
Azevedo et Ventilated in pressure support (PS)
al. [10] mode
With an initial PEEP of 2-10 cm
of water, the pressure-support
level was modified to provide
Frat et al. 7-10 ml expired tidal volume per
[11] kg of anticipated body weight.
Subsequently, the FiO2 or level of
PEEP was modified to sustain a
SpO2 of 92% or higher.
To reduce respiratory distress, IPAP
and EPAP should be adjusted to the
lower end of the following ranges:
IPAP 10-20 cm H2O (or 5-15 cm H2O
Doshi et al. above EPAP) and EPAP 5-10 cm
[9] H2O. At 1.0, FiO2 was started. The
goal was to keep the pulse oximetry
441
value above 88%, maximise
comfort, and reduce respiration rate
to less than 25 breaths in a minute.
The NIV arm's subjects were
administered NIV using a mask or
helmet device that was connected
to an ICU ventilator. The PS setting
Nair et al. was adjusted to 10-20 cm H2O in
[12] order to achieve a 7-10 ml expired
tidal volume per kg of body weight,
and PEEP was set to 5-10 cm H2O
and FiO2 was titrated to target SpO2
>94%.
To maintain tidal volume between
6 and 8 ml/kg and FiO2 adjusted
Elagamy et to retain SpO2 equal to or greater
al. [13] than 92%, the PS level of 8 cm and
PEEP level of 5 cm H2O can both be
increased to 10 cm H2O.
Perkins et Titrate in accordance with each
al. [14] center's own methodology.
Total
Type of NIPPV Comparator Comparator setting Outcomes recorded Select inclusion criteria
number
Acute hypoxic respiratory failure
is characterized by a facemask-
NIPPV full face
HFNC 30 Not mentioned Intubation rate worn oxygen mask and a SpO2
mask
<95%, with an estimated FiO2
of 50%.
Individuals with acute
50 l/minute of gas flow rate and hypoxemic respiratory failure
1.0 FiO2 during start-up. After Complications, patient without hypercapnia received
NIPPV full face that, the amount of oxygen in comfort/dyspnea, high-flow oxygen treatment if
HFNC 216
mask the gas passing through the mortality, and intubation their partial pressure of arterial
system was changed to keep rate. oxygen to fraction of inspired
the SpO2 at 92% or higher. oxygen was 300 mm Hg or
below.
Started with a temperature of
between 35°C and 37°C, 35
l flow rate per minute, and a
FiO2 of 1.0. The temperature Hospital length of stay, Acute respiratory failure
NIPPV full face
HFNC 204 (usually between 35°C and ICU length of stay, and patients who arrive at the
mask
37°C) and flow rate (up to 40 intubation rate. emergency department.
l/minute) were adjusted to
minimize respiratory discomfort
and maximize comfort.
FiO2 was set to 1.0 and the
starting gas flow rate was set Individuals with a laboratory-
at 50 l/minute. After that, the confirmed diagnosis of
Rate of intubation,
flow and FiO2 were changed COVID-19 pneumonia who
Facemask NIV HFNC 104 death, and duration of
to maintain a SpO2 of 94% have severe symptoms and are
hospital stay.
Noninvasive ventilation acute respiratory failure
or higher, ranging from 30 not responding well to oxygen
to 60 l/minute and 0.5-1.0, treatment with a face mask.
respectively.
Rate of intubation,
death rate, length of Adults with weakened immune
NIPPV full face stay in ICU, length of systems who are hospitalized
HFNC 76 Not mentioned
mask stay in hospital, and for acute hypoxemic respiratory
duration of mechanical failure
ventilation.
Rate of intubation,
CPAP
Titrate in accordance with each death, ICU stay duration,
complete face HFNC 791 Hypoxic COVID-19 patients
center's own methodology. hospital stay duration,
mask
and complications.
 Noninvasive ventilation acute respiratory failure

Table 2. Main findings of included studies.

Citation Main findings

There was no discernible difference between HFNC- and NIPPV-managed hypoxemic respiratory failure
Azevedo et al. [10]
patients in terms of the need for invasive ventilation and endotracheal intubation.
Treatment with high-flow oxygen, conventional oxygen, or noninvasive ventilation did not substantially alter
Frat et al. [11] the rate of intubations in patients with nonhypercapnic acute hypoxemic respiratory failure. In terms of 90-day
mortality, there was a substantial difference favoring high-flow oxygen.
When treating adult patients who report to the emergency department with undifferentiated respiratory failure,
Doshi et al. [9]
high-velocity nasal insufflation is a better therapy if compared to noninvasive positive-pressure ventilation.
Neither the intubation rate nor the oxygenation parameters improved statistically significantly between HFNC
Nair et al. [12]
and NIV after 48 hours.
When compared to noninvasive breathing, the use of a high-flow nasal cannula reduces the incidence of
Elagamy et al. [13] endotracheal intubation in immunocompromised patients with ARF while maintaining the same 28-day death
rate.
When compared to COT, an initial CPAP strategy decreased the incidence of tracheal intubation or death in
Perkins et al. [14] individuals with corona virus disease-related acute hypoxemic respiratory failure by a substantial amount.
However, an initial HFNO strategy did not significantly differ from COT.

review. This conclusion appears to be supported by settings to enhance the applicability and accuracy of
earlier RCTs [16] and systematic reviews [4] on the results.
subject; low confidence data suggests that, when
compared to facemask NIPPV, helmet NIPPV may List of Abbreviations
lower mortality and intubation. The physiology may AHRF Acute hypoxemic respiratory failure
be connected to the helmet’s enhanced tolerability ARF Acute respiratory failure
and comfort as well as better positive end-expiratory COT Conventional oxygen therapy
pressure [17]. CPAP Continuous positive airway pressure
EPAP Expiratory positive airway pressure
There are still a lot of unanswered issues about the HFNC High flow nasal cannula
usage of HFNC over NIPPV. For instance, it is still ICU Intensive care unit
unknown what the best oxygenation plan should be IPAP Inspiratory positive airway pressure
for patients with postextubation respiratory failure and NIPPV Nasal intermittent positive pressure ventilation
hypercapnic respiratory failure. Although many of these NIV Non-invasive ventilation
specific populations (hypoxemic respiratory failure, PEEP Positive end-expiratory pressure
postextubation failure, and prophylactic use in high-risk RCT Randomized controlled trials
postoperative patients) are advised by current clinical
guidelines to use HFNC over COT [18], it is unknown Conflict of interests
if NIPPV could offer additional benefits over HFNC. The authors declare that there is no conflict of interest
Patient comfort with HFNC is reported to be higher regarding the publication of this article.
than with the facemask interface, which may outweigh Funding
the possible incremental therapeutic advantage of None.
NIPPV [19]. Regretfully, not enough information about
patient comfort was provided by the included studies Consent to participate
in this review. Although combined dyspnea ratings do Not applicable.
not provide one technology advantage over another,
tolerability, discomfort, or agitation are additional Ethical approval
significant components of comfort that were not measured Not applicable.
or recorded. Therefore, it is unclear and may rely on the
Author details
interface whether HFNC is indeed more pleasant and
Ahmad Saad Alomari1, Sultan Ibrahim Abu Tayli2, Abdulaziz
hence tolerated when compared to NIPPV.
Mohammed A. Alzaydan3, Rayan Bin Abdulrahman Bin
Muneef3, Turki Ibrahim Aljaber4, Renad Bader A. Alsekait4,
Conclusion Shahd Abdulaziz Alabdulathim5, Shoog Khalid Aloleeit5,
When it comes to decreasing the necessity for intubation Wedad Saad Aldhahry6, Wasn Turki Alotaibi7
in hospitalized patients with hypoxemic respiratory 1. Saudi Board Emergency Medicine, Emergency
failure, HFNC and NIPPV could work just as well. Department, First Health Cluster, Riyadh, Saudi Arabia
Additional investigation is required to assess various 2. General Physician, Emergency Department, First Health
interfaces, their financial viability, and in various clinical Cluster, Riyadh, Saudi Arabia

442
 Noninvasive ventilation acute respiratory failure
3. General Physician, College of Medicine, King Saud
University, Riyadh, Saudi Arabia
4. General Physician, College of Medicine, Imam Mohammad
Ibn Saud Islamic University, Riyadh, Saudi Arabia
5. Medical Intern, College of Medicine, King Faisal University,
Alahsa, Saudi Arabia
6. General Physician, College of Medicine, Vision Colleges,
Riyadh, Saudi Arabia
7. General Physician, King Abdulaziz Specialist Hospital, Taif,
Saudi Arabia
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