Continuous Positive Airway Pressure versus High-Flow Nasal Oxygen in Adults with Pneumonia-Related Acute Hypoxemic Respiratory Failure: A Systematic Review and Meta-Analysis.

Authors

Syed Faqeer Hussain Bokhari, Syed Zakria Ali Shah, Hafiz Asad Ullah, Hira Fatima, Mouzma Shafi, Waqar Ali, Maham Zahir, Hasnat Arshad, Hamna Mehmood, Arbeena Shafi, Hashim Nawaz, Menahel Muneer, Samiya Habib, Hajira Ali, Asma Iqbal, Abdul Haseeb Hasan

Published in

Respiratory medicine. Pages 109297. Nov 14, 2026. Epub Nov 14, 2026.

Abstract

Continuous positive airway pressure (CPAP) and high-flow nasal oxygen (HFNO) are both used to avert invasive mechanical ventilation in patients with pneumonia-related acute hypoxemic respiratory failure (AHRF), but head-to-head evidence comparing these two modalities specifically, rather than each against conventional oxygen, remains fragmented.
We searched major databases for studies enrolling adults with pneumonia-related AHRF, including COVID-19-related pneumonia, managed with CPAP versus HFNO. The prespecified primary outcome was intubation within 30 days; secondary outcomes were time to intubation, in-hospital, 30-day, and 90-day mortality, and length of hospital stay.
Seven studies (n=1,551), met the inclusion criteria. CPAP was associated with a significantly lower risk of intubation within 30 days than HFNO (RR 0.75 [0.65-0.86], p<0.0001; I²=33%; moderate certainty of evidence). This benefit was significant among patients with COVID-19 pneumonia (RR 0.75 [0.65-0.86], p<0.0001) but not among those with non-COVID-19 pneumonia (RR 0.67 [0.31-1.45]), although no significant subgroup interaction was detected (p=0.78). CPAP was also associated with a significantly longer time to intubation than HFNO (MD 22.27 hours [16.22-28.33]). No significant differences were observed between CPAP and HFNO for 30-day mortality, 90-day mortality, in-hospital mortality, or length of hospital stay. The reduction in intubation was attenuated but persisted when the analysis was restricted to the four randomized trials (RR 0.81 [0.70-0.95]; I²=0%).
In adults with pneumonia-related AHRF, CPAP probably reduces the risk of intubation compared with HFNO without conferring a mortality advantage or reducing length of stay. HFNO remains a reasonable, generally better-tolerated alternative.

PMID:
43034002
Bibliographic data and abstract were imported from PubMed on 15 Nov 2026.

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