Alternating High-Flow Nasal Oxygen With NIV in the Immunocompromised

Nasal cannula, oxygen therapy
Nasal cannula, oxygen therapy
Does alternating NIV with high flow nasal oxygen reduce mortality or intubation rates in immunocompromised patients with acute respiratory failure?

In immunocompromised patients with acute respiratory failure, the use of noninvasive ventilation (NIV) alternating with high-flow nasal oxygen (HFNO) or HFNO alone does not change the risk of mortality or intubation, according to results of the FLORALI-IM study ( Identifier: NCT02978300) published in Lancet Respiratory Medicine.

HFNO, now widely used to manage acute respiratory failure, may decrease intubation and mortality compared with conventional oxygen therapy in patients with acute hypoxemic respiratory failure, even in comparison with NIV. However, the effectiveness of HFNO compared with NIV in immunocompromised patients has yet to be determined.

Researchers for the current study therefore investigated whether NIV alternating with HFNO vs HFNO alone reduces mortality at day 28 in immunocompromised patients in intensive care due to acute respiratory failure. Between January 21, 2017 to March 4, 2019. The study included patients admitted to 28 intensive care units (ICUs) in France and 1 in Italy. The intention-to-treat analysis included 299 patients, with 154 assigned to the group receiving HFNO alone and 145 assigned to the NIV group.

At day 28, the researchers found that the mortality rate was 36% (56 of 154 patients) in the HFNO alone group and 35% (51 of 145 patients) in the NIV group (absolute difference 1.2%; P =.83). In addition, none of the other prespecified secondary outcomes were different between the groups except for greater decreased discomfort after initiation of HFNO than with NIV (–4 mm on a visual analogue scale vs 0 mm; P =.040).

The researchers concluded, “In critically ill immunocompromised patients with acute respiratory failure, the mortality rate did not differ between HFNO alone and NIV alternating with HFNO.” However, they also noted that the study power was limited, so the results should be interpreted with caution.

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures. 


Coudroy R, Frat J-P, Ehrmann S, et al; FLORALI-IM study group and the REVA Research Network. High-flow nasal oxygen alone or alternating with non-invasive ventilation in critically ill immunocompromised patients with acute respiratory failure: a randomised controlled trial. Lancet Respir Med. Published online March 21, 2022. doi:10.1016/S2213-2600(22)00096-0