Written by Jason Lesnick
Spoon Feed
This RCT found that high-flow nasal oxygen (HFNO) was noninferior to noninvasive ventilation (NIV) for patients with acute respiratory failure (ARF) who aren’t immunocompromised; however, there are multiple limitations.
How do I pronounce “HFNO”?
This study compares HFNO to NIV for a variety of causes of acute respiratory failure. There have been studies in the past that found similar efficacy between HFNO and NIV for hypoxic respiratory failure. This multicenter noninferiority RCT randomized 1,766 adults across 33 hospitals in Brazil from 2019 to 2023 and investigated if HFNO was noninferior to NIV on rates of intubation or death at 7 days in 5 groups with ARF: immunocompromised (IC) with hypoxemia, non-IC with hypoxemia, COPD exacerbation with respiratory acidosis, acute cardiogenic pulmonary edema (ACPE), or hypoxemic COVID-19. Data were assessed using a Bayesian hierarchical model with dynamic borrowing across patient groups. Noninferiority was defined by a posterior probability (NPP) of 0.992 or greater for an odds ratio (OR) less than 1.55.
The primary outcome of intubation or death at 7 days occurred in 39% (344/883) of the HFNO group vs 38% (336/883) NIV. HFNO met prespecified criteria for noninferiority for the primary outcome in 4 of the 5 subgroups, but not in IC patients.
How will this change my practice?
When treating respiratory failure in my IC patients, I may move to NIV more rapidly after reading this study. However, the authors acknowledge that additional research is needed due to small subgroup sample sizes, exclusion of the sickest ACPE patients, and differing results when analyzed without borrowing.
Source
High-Flow Nasal Oxygen vs Noninvasive Ventilation in Patients With Acute Respiratory Failure: The RENOVATE Randomized Clinical Trial. JAMA. 2024 Dec 10. doi: 10.1001/jama.2024.26244. Epub ahead of print. PMID: 39657981
