Comparative effectiveness of non‑invasive oxygenation strategies in acute hypoxemic respiratory failure: a systematic review and network meta‑analysis of randomized controlled trials

Acute hypoxemic respiratory failure (AHRF) is a common and life‑threatening condition requiring prompt and effective respiratory support. Non‑invasive oxygenation strategies including Conventional oxygen therapy (COT), high‑flow nasal oxygen (HFNO), and non‑invasive ventilation (NIV) are widely used, yet their comparative effectiveness remains uncertain. To evaluate and compare the efficacy and safety of non‑invasive oxygenation strategies in patients with AHRF using a systematic review and network meta‑analysis. A systematic search of major electronic databases PubMed, MEDLINE, Embase, CINAHL, Cochrane Library and Google Scholar for studies and included randomized controlled trials (RCTs) in adults comparing NIVM with COT. The primary outcome was to independently evaluate all-cause mortality and intubation rates in adults with acute hypoxemic respiratory failure (AHRF) at 30 days or hospital discharge. Secondary outcomes included hospital-acquired pneumonia, improvement in PaO₂/FiO₂ ratio, and length of hospital and ICU stay. Two researchers independently conducted literature screening, data extraction and quality evaluation. A Meta-analysis was performed using Review Manager (RevMan). Twenty-five RCTs involving 3,802 patients were included, of whom 58% received NIVM. Compared with COT, all NIVM strategies significantly reduced mortality: helmet NIV (OR 0.18; 95% CI 0.08–0.42), HFNC (OR 0.49; 95% CI 0.31–0.77), and face mask NIV (OR 0.70; 95% CI 0.50–0.98). Similarly, intubation rates were significantly reduced with helmet NIV (OR 0.12; 95% CI 0.05–0.28), HFNC (OR 0.50; 95% CI 0.33–0.75), and face mask NIV (OR 0.55; 95% CI 0.41–0.74). Helmet NIV was associated with a significant reduction in hospital-acquired pneumonia (OR 0.18; 95% CI 0.06–0.52), whereas HFNC showed a non-significant trend toward reduction (OR 0.35; 95% CI 0.11–1.10). Noninvasive oxygenation methods improve clinical outcomes in adults with AHRF compared with conventional oxygen therapy. Helmet‑NIV indicates potential clinical advantage and may be used in patients chosen on clinical grounds, with the greatest observed reductions in mortality, intubation, and nosocomial pneumonia.