Nasal high‐flow therapy compared with non‐invasive ventilation in COPD patients with chronic respiratory failure: A randomized controlled cross‐over trial

Abstract

Background and objective: Non-invasive ventilation (NIV) is part of the standard of care for hypercapnic respiratory failure secondary to COPD, but may be poorly tolerated. Preliminary evidence suggests nasal high-flow (NHF) therapy may improve hypercapnia in COPD and be well tolerated. We compared NHF and NIV in people with COPD and chronic hypercapnic respiratory failure. Methods: Single-blind randomized controlled two-way cross-over single-centre trial was conducted in New Zealand. Twenty-four participants with stable hypercapnic COPD received: NHF at 45 L/min and NIV at 15/4 cm H 2 O, each for 60 min with a 15-min washout in between. The primary outcome was transcutaneous partial pressure of carbon dioxide (PtCO 2 ) at 60 min, adjusted for baseline. Results: NIV reduced the PtCO 2 more than NHF (mean (SD) at 60 min by −5.3 (5.0) vs −2.5 (3.5) mm Hg; difference: −2.8 (−5.0 to −0.5) P = 0.021). Difference across all time points was −2.5 mm Hg (95% CI −4.5 to −0.5, P = 0.016). There was no significant difference in the proportion of participants with a reduction of PtCO 2 ≥ 4 or ≥ 8 mm Hg. Participants rated NHF significantly better for ease of application, comfort and fit. Conclusion: In stable COPD patients with chronic hypercapnia, NIV resulted in a greater reduction in PtCO 2 compared with NHF, which was of uncertain clinical significance. NHF was better tolerated than NIV and may be a therapeutic option for some people with hypercapnic respiratory failure. Clinical Trial Registration: ACTRN12616001701415 at www.anzctr.org.au

Contemporary Concise Review 2019: Chronic obstructive pulmonary disease

“…McKinstry et al . performed a randomized cross‐over trial to compare the efficacy of nasal high‐flow therapy against NIMV in stable hypercapnic COPD patients and showed that nasal high‐flow therapy was able to reduce patients' PaCO 2 ; however, overall, it was less effective than NIMV in reducing PCO 2 (by ~3 mm Hg) . As expected, nasal high‐flow therapy was much better tolerated than NIMV.…”

“…A more novel approach may be using nasal high‐flow therapy, which delivers humidified air (with or without supplemental oxygen) and is much better tolerated compared with NIMV . McKinstry et al .…”

“…A more novel approach may be using nasal highflow therapy, which delivers humidified air (with or without supplemental oxygen) and is much better tolerated compared with NIMV. 13 McKinstry et al performed a randomized cross-over trial to compare the efficacy of nasal high-flow therapy against NIMV in stable hypercapnic COPD patients and showed that nasal high-flow therapy was able to reduce patients' PaCO 2 ; however, overall, it was less effective than NIMV in reducing PCO 2 (by~3 mm Hg). 13 As expected, nasal high-flow therapy was much better tolerated than NIMV.…”

“…13 McKinstry et al performed a randomized cross-over trial to compare the efficacy of nasal high-flow therapy against NIMV in stable hypercapnic COPD patients and showed that nasal high-flow therapy was able to reduce patients' PaCO 2 ; however, overall, it was less effective than NIMV in reducing PCO 2 (by~3 mm Hg). 13 As expected, nasal high-flow therapy was much better tolerated than NIMV. Although this study was not powered on clinical endpoints and did not evaluate patients who were acutely exacerbating, these data nonetheless provide optimism that high-flow therapy may be useful in some patients with hypercapnic respiratory failure, who are unable to tolerate NIMV.…”

Nasal high‐flow therapy: Established roles and emerging opportunities

“…McKinstry et al . have performed a randomized crossover study comparing NHF to NIV in stable hypercapnic subjects with obstructive lung disease and have also showed a measurable reduction in transcutaneous CO 2 of 2.5 mm Hg, which is, however, inferior to the 5.3 mm Hg reduction achieved with NIV . Another prior prospective study examined the effect of NHF on transcutaneous CO 2 in acutely exacerbating hypercapnic patients and similarly found a measurable but smaller reduction of 1.4 mm Hg .…”