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Background  High-flow nasal cannula oxygen (HFNC) is a relatively new therapy used in adults with respiratory failure. Whether it is superior to conventional oxygen therapy (COT) or to noninvasive mechanical ventilation (NIV) remains unclear. The aim of the present study was to investigate whether HFNC was superior to either COT or NIV in adult acute respiratory failure patients.    Methods  A review of the literature was conducted from the electronic databases from inception up to 20 October 2016. Only randomized clinical trials comparing HFNC with COT or HFNC with NIV were included. The intubation rate was the primary outcome; secondary outcomes included the mechanical ventilation rate, the rate of escalation of respiratory support and mortality.    Results  Eleven studies that enrolled 3459 patients (HFNC,  n  = 1681) were included. There were eight studies comparing HFNC with COT, two comparing HFNC with NIV, and one comparing all three. HFNC was associated with a significant reduction in intubation rate (OR 0.52, 95% CI 0.34 to 0.79,  P  = 0.002), mechanical ventilation rate (OR 0.56, 95% CI 0.33 to 0.97,  P  = 0.04) and the rate of escalation of respiratory support (OR 0.45, 95% CI 0.31 to 0.67,  P  < 0.0001) when compared to COT. There was no difference in mortality between HFNC and COT utilization (OR 1.01, 95% CI 0.67 to 1.53,  P  = 0.96). When HFNC was compared to NIV, there was no difference in the intubation rate (OR 0.96; 95% CI 0.66 to 1.39,  P  = 0.84), the rate of escalation of respiratory support (OR 1.00, 95% CI 0.77 to 1.28,  P  = 0.97) or mortality (OR 0.85, 95% CI 0.43 to 1.68,  P  = 0.65).    Conclusions  Compared to COT, HFNC reduced the rate of intubation, mechanical ventilation and the escalation of respiratory support. When compared to NIV, HFNC showed no better outcomes. Large-scale randomized controlled trials are necessary to prove our findings.    Trial registration  PROSPERO International prospective register of systematic reviews on May 25, 2016 registration no.  CRD42016039581 .    Electronic supplementary material  The online version of this article (doi:10.1186/s13054-017-1760-8) contains supplementary material, which is available to authorized users.

critical care

High-flow nasal cannula oxygen therapy is superior to conventional oxygen therapy but not to noninvasive mechanical ventilation on intubation rate: a systematic review and meta-analysis