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

BACKGROUND: The use of nasal high-flow (NHF) oxygen for apnoeic oxygenation during emergency paediatric intubation is not universally adopted. Although previous studies suggest potential benefits, it remains unclear whether NHF enhances the likelihood of achieving successful first-attempt intubation without oxygen desaturation in children. We aimed to investigate whether the provision of NHF oxygen during paediatric emergency intubation can improve intubation outcomes.

METHODS: We conducted a randomised, controlled, open-label trial at ten hospitals in Australia, New Zealand, and Switzerland (four emergency departments, ten paediatric intensive care units, and one non-maternity neonatal intensive care unit were included). Children younger than 16 years undergoing emergency endotracheal intubation were eligible for inclusion. Participants were randomly assigned (1:1) to receive either NHF apnoeic oxygenation or standard care during intubation. The primary outcomes were the occurrence of hypoxaemic events (defined as oxygen saturation [SpO 2] ≤90%) and successful intubation on the first attempt without desaturation in the modified intention-to-treat population (all intubations in participants for whom prospective or retrospective consent was given and a primary outcome was recorded). This trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12617000147381) and is now completed.

FINDINGS: Between May 9, 2017, and Oct 22, 2022, 1069 intubations in 969 children were randomly assigned to the NHF group (535 intubations) or standard care group (534 intubations). The primary analysis comprised 950 intubations in 860 children, with 476 intubations in the NHF group and 474 in the standard care group. In the NHF group, hypoxaemic events occurred in 61 (12·8%) of 476 intubations, compared with 77 (16·2%) of 474 in the standard care group (adjusted odds ratio [aOR] 0·74; 97·5% CI 0·46-1·18; p=0·15). Successful intubation was achieved at the first attempt in 300 (63·0%) of 476 intubations in the NHF group and 280 (59·1%) of 474 intubations in the standard care group (aOR 1·13; 97·5% CI 0·79-1·62; p=0·43). In the per-protocol analysis of 905 intubations, NHF reduced the rate of hypoxaemia (48 [10·8%] of 444) compared with standard care (77 [16·7%] of 461; aOR 0·59; 97·5% CI 0·36-0·97; p=0·017). In this analysis, first-attempt successful intubation was achieved in 284 (64·0%) of 444 intubations in the NHF group versus 268 (58·1%) of 461 intubations in the standard care group (aOR 1·22; 97·5% CI 0·87-1·71; p=0·19).

INTERPRETATION: The use of NHF during emergency intubation in children did not result in a reduction in hypoxaemic events or an increase in the frequency of successful intubation on the first attempt. However, in the per-protocol analysis, there were fewer hypoxaemic events but no difference in successful intubation without hypoxaemia on first attempt. Barriers to the application of NHF during emergency intubation and the reasons for abandoning intubation attempts before physiological compromise should be further investigated to inform future research and recommendations for intubation guidelines and clinical practice.

FUNDING: Thrasher Research Fund (USA), National Health and Medical Research Council (Australia), and the Emergency Medicine Foundation (Australia).