NHFT versus NIV in hypoxemic respiratory failure without the need for intubation

Simon Oczkowski, MD, MHSc, MSc, is an associate professor of medicine in the Division of Critical Care at McMaster University.

Should we use nasal high-flow therapy (NHFT) before noninvasive ventilation (NIV) in most cases of acute hypoxemic respiratory failure without the need for intubation?

In general, the evidence is very strong, supporting NHFT over conventional oxygen therapy in patients with really anything more than mild respiratory failure.

The evidence is less clear about the role of NIV versus NHFT. Some of the earlier studies actually suggested NHFT may be a more effective form of treatment. But the number of studies that we have is actually fairly small, so we’re not totally certain of the effects.

When I’m trying to decide whether or not to use NHFT before NIV, I primarily think about other factors related to the patient. Is this a patient with congestive heart failure? Because we know that NIV is the preferred treatment in those patients. Or is this a patient who already uses NIV at home? In those sorts of patients, I know that they’re going to likely tolerate the treatment and they might reach for NIV first. But the ease of use, the simplicity, the patient comfort with NHFT really do make it the primary choice that I and most other clinicians reach for in hypoxic respiratory failure.