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6 PEM papers that could change your practice – #5 – high flow nasal oxygen


Simon Binks, an Emergency Medicine doc in Wollongong Hospital recently gave an awesome talk on six papers that changed his paediatric emergency medicine practice in the last year. This week we are posting one each day. You can hear the talk on Joe Lex’s Free Emergency Medicine Talks site.

See all the papers and discussion:

  1. The downsides of codeine in kids
  2. The outcomes of absorbable sutures in facial lacerations
  3. Abdo x-rays to rule out intussusception
  4. Bloods markers as predictors of serious bacterial infection
  5. High flow nasal cannulae for acute respiratory insufficiency
  6. Getting urine from neonates

Here I summarise the fifth paper he identified and his key points.

 5. High flow nasal cannula – help or hindrance?

High flow nasal cannula is becoming more popular in Paediatrics EDs. Essentially it allows us to supply humidified high flow oxygen and some degree of CPAP (up to 5cm H2O) to patients in respiratory distress. But is it helpful?

An article in Pediatric Emergency Care looked at whether high flow nasal cannulas affected intubation and outcome in patients with acute respiratory insufficiency.

Who were the patients?

This was a retrospective study of ED patients with acute respiratory insufficiency who were subsequently admitted to PICU.

Acute respiratoy insufficency was defined as: hypoxia; increased work of breathing; or poor compliance with oxygen mask. Most of these these patients had asthma, bronchiolitis, or croup.

There were 848 patients.

What was the intervention?

The authors examined the effect of the introduction of high flow nasal cannula protocols in their ED – they looked at patients before and after the introduction of their high flow nasal cannula protocol.

Specifically the outcome analysed was the number of intubations in those patients.

What did they find?

PICU rates of admission were unchanged between the two groups.

The intubation rate halved overall (for intubation in ED and later intubation in ICU). This was statistically significant in asthma and bronchiolitis patients.

Length of stay, ventilation days and the mortality rates were unchanged between the groups – so high flow does not simply delay or prolong the need for ventilation.

There was one complication of high flow nasal cannula, which was bilateral pneumothoraces.

It is reassuring that in bronchiolitics and asthmatics, high flow nasal cannula administered early on can benefit patients and reduce their risk of intubation in ED or subsequently in PICU. However, that was just a retrospective study, so an RCT would be of great benefit.



Wing R, James C, Maranda LS, Armsby CC. Use of high-flow nasal cannula support in the emergency department reduces the need for intubation in pediatric acute respiratory insufficiency. Pediatr Emerg Care. 2012 Nov;28(11):1117-23.






  • Tessa Davis is a Consultant in Paediatric Emergency Medicine at the Royal London Hospital and a Senior Lecturer at Queen Mary University of London.

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