Impact of High-Flow Nasal Cannula for Chronic Obstructive Pulmonary Disease Exacerbation: A Systematic Review of Clinical and Physiological Outcomes.

BACKGROUND

Chronic obstructive pulmonary disease (COPD) caused 3.72 million deaths in 2021. Exacerbations drive morbidity and hospital admissions. Conventional oxygen therapy (COT) offers limited support, while non-invasive ventilation (NIV) improves outcomes but is often poorly tolerated. High-flow nasal cannula (HFNC) delivers heated, humidified oxygen at high flow rates, improving gas exchange and comfort. This systematic review (PRISMA-guided) examines HFNC use in acute and chronic hypercapnic COPD compared with COT and NIV.

METHODS

Systematic searches of MEDLINE, Embase and CENTRAL (to 2025) identified 14 primary studies (7 randomized trials, 7 observational cohorts). Physiological, clinical and patient-reported outcomes were extracted. Risk of bias was evaluated using RoB 2 and ROBINS-I.

RESULTS

In acute settings, HFNC consistently improved PaCO2 and reduced respiratory effort versus COT, lowering treatment failure (10.0% vs 19.4%, p=0.026). However, HFNC failed non-inferiority versus NIV for treatment failure (25.7% vs 14.3%) and showed higher intubation (14.2% vs 5.4%, p=0.026). Domiciliary HFNC reduced annual exacerbations and improved quality of life (SGRQ mean difference -8.12).

CONCLUSION

HFNC provides physiological benefits and lowers short-term failure versus COT and reduces home exacerbations. However, it is less effective than NIV for severe hypercapnic failure. HFNC should be reserved for mild-to-moderate exacerbations or NIV-intolerant patients, with close monitoring and predefined escalation criteria.