High-Flow Nasal Cannula (HFNC) Versus Conventional Oxygen Therapy in the Prevention of Post-extubation Hypoxemia: A Systematic Review and Network Meta-Analysis

TL;DR

This study compares high-flow nasal cannula and noninvasive ventilation to conventional oxygen therapy in preventing breathing problems after extubation in ICU patients.

Contribution

A network meta-analysis comparing HFNC, NIV, and COT for post-extubation hypoxemia prevention in ICU patients.

Findings

HFNC and NIV significantly reduce reintubation risk compared to COT.

NIV was ranked most effective, followed by HFNC and then COT.

HFNC is a reliable alternative to NIV due to its ease of use and comparable performance.

Abstract

Respiratory failure following extubation is a major contributor to patient morbidity and death in intensive care settings. While various methods exist, the relative effectiveness of high-flow nasal cannula (HFNC), noninvasive ventilation (NIV), and conventional oxygen therapy (COT) in preventing reintubation remains an area of active research. This systematic review and network meta-analysis assessed these techniques in adult patients after scheduled extubation. A search of MEDLINE, Embase, and Cochrane CENTRAL was performed for relevant randomized controlled trials (RCTs) available up to December 2025. Data extraction was performed independently by two researchers. To synthesize findings, a random-effects network meta-analysis was employed, focusing on reintubation rates within a 72-hour window as the primary endpoint. Results were expressed as risk ratios (RR) accompanied by 95% confidence intervals (CI), and the Confidence in Network Meta-Analysis (CINeMA) tool was used to evaluate evidence quality. The analysis included 14 RCTs involving a total of 4,146 participants. Results indicated that both NIV (RR 0.56; 95% CI 0.34-0.94) and HFNC (RR 0.68; 95% CI 0.47-0.97) significantly decreased the reintubation risk when compared to COT. No significant difference in efficacy was observed between HFNC and NIV (RR 1.20; 95% CI 0.76-1.89). Based on surface under the cumulative ranking curve (SUCRA) rankings, NIV emerged as the most effective intervention (88% probability), followed by HFNC (60%) and then COT (2%). The certainty of evidence was moderate for comparisons involving COT, but low for the HFNC versus NIV comparison because of imprecision. HFNC and NIV are more effective than COT at preventing reintubation in the ICU. HFNC serves as a dependable preventative measure due to its ease of application and performance comparable to NIV. These findings support a shift away from standard COT toward more advanced noninvasive respiratory support.

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