UMEM Educational Pearls

Title: HFNO vs. NIV in Respiratory Failure: The RENOVATE Trial

Posted: 4/22/2025 by Cody Couperus-Mashewske, MD
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This large RCT compared High-Flow Nasal Oxygen (HFNO) against Noninvasive Ventilation (NIV) via face mask in 5 types of Acute Respiratory Failure (ARF): non-immunocompromised hypoxemia, immunocompromised hypoxemia, COPD with acidosis, acute cardiogenic pulmonary edema (ACPE), and COVID-19.

Primary Finding: For the main outcome (7-day intubation/death), HFNO was found noninferior to NIV in 4 groups (non-immunocompromised, COPD, ACPE, COVID-19) using a Bayesian model with data borrowing. Futility was declared for the immunocompromised group.
Major Caveat: A post-hoc analysis without data borrowing yielded conflicting results:
- Potential Harm: Suggested HFNO might be inferior or harmful in COPD with acidosis and immunocompromised patients.
- Potential Benefit: Suggested HFNO might be superior in ACPE (though sicker ACPE patients needing prior NIV were excluded).
Other Points: No difference in 28/90-day mortality was seen. HFNO was more comfortable. Rescue NIV was needed for ~23% of COPD patients started on HFNO.

Bottom Line:
RENOVATE suggests HFNO might be a reasonable, more comfortable initial choice for non-immunocompromised hypoxemic ARF or COVID-19 ARF. However, exercise caution using HFNO first-line for COPD exacerbations with acidosis or immunocompromised hypoxemic ARF due to conflicting analyses and potential harm signals. The signal for HFNO benefit in ACPE is intriguing but needs confirmation before changing practice. Close monitoring for failure and timely escalation are essential regardless of the initial noninvasive strategy.

References

High-flow nasal oxygen vs noninvasive ventilation in patients with acute respiratory failure: the RENOVATE randomized clinical trial RENOVATE Investigators and the BRICNet Authors, Maia IS, Kawano-Dourado L, et al. JAMA. Published online December 10, 2024. doi:10.1001/jama.2024.26244