Major international study on respiratory support in critical illness

HN Summary

• A major international study led by Scarborough Health Network found that CPAP, high-flow nasal cannula and bilevel non-invasive ventilation can reduce the need for invasive ventilation in critically ill patients with acute hypoxaemic respiratory failure.

• The analysis of 44 clinical trials involving more than 9,700 patients also found that CPAP and high-flow nasal cannula may improve survival compared with standard oxygen therapy.

• Researchers say the findings provide stronger evidence to guide critical care decisions and support the early use of non-invasive respiratory therapies to improve patient outcomes.

A new international study led by Dr. Christopher Yarnell, an intensive care physician at Scarborough Health Network (SHN), is helping answer an important question in critical care: what is the most effective way to support patients who are struggling to breathe without needing to use a ventilator?

Published in The Lancet Respiratory Medicine, the study is among the most comprehensive analyses to date on non-invasive respiratory support. Drawing on data from 44 clinical trials and more than 9,700 patients worldwide, Dr. Yarnell’s and his co-authors’ research provides valuable clarity for clinicians treating some of the sickest patients in hospital. The study’s first author was Kevin Lee, a medical student at the University of Ottawa. Dr. Peter Reardon and nurse Thecla Kattakkayam from SHN were also co-authors.

Understanding a common and serious condition

The study focuses on acute hypoxaemic respiratory failure (AHRF), a condition in which the lungs cannot provide enough oxygen to the body. This is a common reason patients are admitted to intensive care units (ICUs), accounting for up to 15 per cent of ICU admissions.

Patients with AHRF often need help breathing. In severe cases, this involves invasive ventilation, where a breathing tube is inserted into the airway and connected to a machine to provide oxygen to the lungs when the patient cannot do so adequately on their own. While potentially lifesaving, this approach can come with risks such as infections, physical distress, and longer recovery times.

Whenever possible, clinicians aim to use non-invasive respiratory support, which helps patients breathe using masks or nasal devices. These methods can reduce complications and improve patient comfort, but until now, it has not been entirely clear which non-invasive approach is the most effective for more severe cases.

Dr. Yarnell and his colleagues examined four commonly used non-invasive methods:

• Continuous positive airway pressure (CPAP), which delivers steady air pressure via a tight-fitting face-mask to keep airways open;

• High-flow nasal cannula (HFNC), which provides warm, humid oxygen through the nose at high flow rates;

• Bilevel non-invasive positive pressure ventilation (NIPPV), which alternates between higher and lower pressures via a tight-fitting facemask to assist breathing;

• And standard oxygen therapy, where oxygen is delivered at low flows by a loose-fitting mask or nasal prongs.

The findings showed that CPAP, HFNC, and bilevel NIPPV all reduce the need for invasive ventilation compared with standard oxygen therapy. Another finding was that CPAP and HFNC may improve survival. Results were the same in comparable studies that used both specific criteria and case-by-case judgment for switching to invasive ventilation. This means the results apply to real-world critical care contexts.

“Our results show that these therapies are consistently helpful for patients with major breathing problems, regardless of whether intubation decisions are guided by judgment or specific criteria,” shared Dr. Yarnell. “This is very exciting, because it validates the approach we take at SHN. We use CPAP, HFNC, and bilevel NIPPV to try and avoid invasive ventilation while supporting patients during their illness.”

By strengthening confidence in these approaches, the study helps support safer, more effective treatment decisions for critically ill patients.

“This study reinforces what we see at the bedside every day—that thoughtful use of non-invasive respiratory support can meaningfully change a patient’s care journey,” said Dr. Martin Betts, Chief of Critical Care. 

“It can give healthcare professionals greater confidence to act early and avoid invasive ventilation when possible, while also reflecting the kind of practice-led research at SHN that is directly shaping how critical care is delivered.”

Building better care through discovery

Dr. Yarnell is a clinician-scientist in SHN’s Department of Critical Care and a researcher with the SHN Research Institute. He is also affiliated with the University of Toronto’s Interdepartmental Division of Critical Care Medicine. This latest publication highlights SHN’s growing impact in high-quality clinical research with global reach.

“This work demonstrates how our physicians are contributing to international conversations in critical care,” shared Dr. Samir Grover, Executive Vice President of Academics at SHN. “Dr. Yarnell’s work helps ensure that the care we provide is grounded in the best available evidence, ultimately improving outcomes for patients both here in Scarborough and around the world.”

In addition to its key findings, the study points to areas for future research, including the importance of learning more about whether and when to use invasive ventilation in patients with AHRF. Another observational study led by Dr. Yarnell, currently recruiting patients at all 3 SHN hospitals, aims to address that exact problem.  

As SHN continues to expand its research programs, studies like this reflect a broader commitment to advancing patient-centred care through rigorous, impactful science.

By helping clinicians better understand how to support breathing in critically ill patients, Dr. Yarnell is contributing to safer, more effective care for some of the most vulnerable people in the health system, and reinforcing SHN’s role as a leader in research and innovation.

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