A MAJOR international trial has assessed whether nasal high-flow (NHF) oxygen improves outcomes during emergency paediatric intubation but found no significant benefit in the primary analysis.
The study was a randomised, controlled, open-label trial conducted across ten hospitals in Australia, New Zealand, and Switzerland. Eligible participants were children under 16 undergoing emergency endotracheal intubation. Patients were randomised 1:1 to receive either NHF apnoeic oxygenation or standard care. Primary outcomes were the rate of hypoxaemic events (defined as oxygen saturation ≤90%) and successful first-attempt intubation without desaturation, in a modified intention-to-treat population. A per-protocol analysis was also conducted.
Between May 2017–October 2022, 1,069 intubations were randomised: 535 to NHF and 534 to standard care. The primary analysis included 950 intubations. Hypoxaemic events occurred in 12.8% of NHF intubations and 16.2% of standard care cases (adjusted odds ratio [aOR]: 0.74; 97.5% CI: 0.46–1.18; p=0.15). Successful intubation on first attempt occurred in 63.0% of NHF intubations and 59.1% of standard care cases (aOR: 1.13; 97.5% CI: 0.79–1.62; p=0.43). In the per-protocol analysis (905 intubations), NHF reduced hypoxaemia to 10.8% from 16.7% (aOR: 0.59; 97.5% CI: 0.36–0.97; p=0.017), although there was no significant improvement in first-attempt success (64.0% vs 58.1%; aOR: 1.22; 97.5% CI: 0.87–1.71; p=0.19).
NHF oxygenation did not improve primary outcomes in the intention-to-treat analysis, though per-protocol data suggest a possible reduction in hypoxaemia. Further research is needed to address barriers to NHF implementation and refine paediatric intubation strategies.
Reference
George S et al; Paediatric Research in Emergency Departments International Collaborative research networks and the Australian and New Zealand Intensive Care Society Paediatric Study Group. Effectiveness of nasal high-flow oxygen during apnoea on hypoxaemia and intubation success in paediatric emergency and ICU settings: a randomised, controlled, open-label trial. Lancet Respir Med. 2025;13(6):545-55.
