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Article pour les cliniciens

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High-Flow Nasal Oxygen vs Noninvasive Ventilation in Patients With Acute Respiratory Failure: The RENOVATE Randomized Clinical Trial.

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• Maia IS
• Kawano-Dourado L
• Tramujas L
• de Oliveira NE
• Souza RN
• Signorini DF, et al.

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Commentaires cliniques (en anglais)

Cardiology

Overall pretty big "n" suggesting "dealer's choice" in most cases would work. Although based on the mode of action in some cases, we would select one modality over another depending on suspected pathophysiology.

Emergency Medicine

This is an ambitious RCT to answer the question: Is high-flow nasal oxygen (HFNO) noninferior to noninvasive ventilation (NIV) for rate of endotracheal intubation or death at 7 days in patients with acute respiratory failure? This was done in 33 Brazilian hospitals over a 4-year period using sophisticated statistical planning and analysis. The patient groups analyzed separately were nonimmunocompromised with hypoxemia, immunocompromised with hypoxemia, COPD exacerbation with respiratory acidosis, acute cardiogenic pulmonary edema, or hypoxemic COVID-19. No difference was found between HFNO and NIV for 4 of the groups. One patient group (immunocompromised with hypoxemia) was stopped for futility; only 50 patents enrolled. (The primary outcome occurred in 57% in the HFNO group vs 36% in the NIV group.) Overall, no difference in the incidence of serious adverse events was found.

Emergency Medicine

The non-inferiority conclusions among those with COPD and acute cardiogenic pulmonary edema is concerning when there is biologic plausibility for NIV to be superior, and the point estimates favor NIV when NIV is widely available with no clear signal of NIV harms. The results in the nonimmunocompromised with hypoxemia and hypoxemic COVID-19 groups are interesting, although sometimes in the acute care setting the etiology of dyspnea (CHF vs COPD vs COVID) is unclear, so uncertain how these results might be used amid that diagnostic uncertainty.

Emergency Medicine

HFNC is non-inferior compared with non-invasive positive pressure ventilation (e.g., BiPAP/CPAP) for hypoxic respiratory failure. While this is at least consistent with other recent literature, there are a number of caveats: 1) patients who were immunocompromised, did not meet non-inferiority and thus cannot be included in this; 2) it's unclear whether "sicker" patients with COPD or pulmonary edema would also benefit as some analysis would suggest otherwise (e.g., a large number of patients in the COPD had crossed over into non-invasive); 3) since this treatment isn't "superior", it's unclear whether this is more cost-effective versus non-invasive PPV; and 4) secondary outcomes were not statistically significant, thus a bigger picture of benefit is unclear. Regardless, it is an option and at least for some scenarios, is non-inferior (and easier to tolerate) than NIPPV.

Hospital Doctor/Hospitalists

The definition of non-inferiority in this study was generous at an OR < 1.55. That being said the point estimates were well centered and the upper ends of the 95% CIs were quite reasonable.

Hospital Doctor/Hospitalists

Useful information for almost any hospitalist as ARF is exceedingly common. Being aware of the benefits (or lack thereof) of therapy escalation is important!

Intensivist/Critical Care

Interesting trial but complicated to apply to practice and not sure it's practice-changing.

Intensivist/Critical Care

The comparative effectiveness of noninvasive ventilation versus high flow nasal cannula (HFNC) in hypoxemic respiratory failure has been much debated. This article should reassure clinicians about using HFNC, even in some surprising conditions (e.g., COPD with acidosis) in patients intolerant of noninvasive ventilation. The main concerns are: 1) the eligibility criteria do not necessarily reflect routine practice (patients were initiated on HFNC or noninvasive with modest degrees of hypoxemia); and 2) the primary analysis and the post-hoc sensitivity analysis have discrepant results, suggesting that the underlying assumptions about similarities in treatment effect in the primary analysis may not be valid

Respirology/Pulmonology

The authors should be commended for enrolling a large number of participants over several years. The choice between high-flow nasal oxygen (HFNC) and noninvasive ventilation (NIV) in acute respiratory failure primarily rests on the work of breathing and relies on clinical judgment. The results of the study are not surprising, considering NIV is known to be most helpful for those with increased work of breathing or hypercapnic respiratory failure and the minimal proportion of the participants was hypercarbic. This study reassures that HFNC is noninferior to NIV in acute hypoxemic respiratory failure, which is consistent with the existing literature.

Respirology/Pulmonology

This adaptive RCT finds that oxygen by high-flow nasal cannula was noninferior to noninvasive ventilation in patients with acute respiratory failure. This is important validation of HFNC, which is now widely used in practice as it is much more comfortable for patients and may allow management in less closely monitored settings.