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Original Articles

Pediatrics
High-flow nasal cannula for respiratory support in children with severe asthma attack: a systematic review and meta-analysis: Ghea Mangkuliguna, Muhammad Ifan Romli, Adrian Djatikusumo, Nicholas Adrianto; Acute Crit Care. 2026;41(1):148-159. Published online October 24, 2025; DOI: https://doi.org/10.4266/acc.003744

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188 Download
1 Web of Science
1 Crossref

Abstract PDF

Background
Adjunctive therapies, including high-flow nasal cannula (HFNC) and bilevel positive airway pressure, have been explored to manage severe asthma attacks and avoid invasive ventilation. HFNC has gained interest as a potential alternative. This review evaluated and compared outcomes of HFNC with conventional oxygen therapy or other non-invasive ventilation (NIV) in severe asthma. Methods: A comprehensive search of PubMed/Medline, Scopus, Cochrane Library, and gray literature identified studies published between August 25, 2014, and August 25, 2024. A random-effects meta-analysis was performed, and results were presented in a forest plot. Study quality was assessed using the Cochrane Risk of Bias tool (ROB-2) and Newcastle-Ottawa Scale. The review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines and was registered in PROSPERO (CRD42024558656). Results: Nine studies with 14,606 subjects were included. HFNC showed a trend toward improved pulmonary scores, though not statistically significant (P>0.05). Pediatric intensive care unit (PICU) admission and need for escalation of support did not significantly differ from standard oxygen therapy or other NIV. HFNC was associated with a modest but significant increase in readmission (odds ratio, 3.14; 95% CI, 1.07–9.24; P=0.04). PICU length of stay was comparable across groups, and mortality among HFNC-treated patients remained <1%. Overall evidence quality was very low to low. Conclusions: HFNC did not demonstrate superior outcomes over conventional oxygen therapy and other NIV. Evidence remains limited and of low quality, highlighting the need for further high-quality studies.

Citations

Citations to this article as recorded by

Respiratory Support in Pediatric Critical and Near-Fatal Asthma: A Narrative Review
Long Xiang, Herng Lee Tan, Andrew Miller, Alexandre T. Rotta, Jan Hau Lee
Pulmonary Therapy.2026; 12(3): 819. CrossRef

Pulmonary
Combining reservoir mask oxygenation with high-flow nasal cannula in the treatment of hypoxemic respiratory failure among patients with COVID-19 pneumonia: a retrospective cohort study: Ivan Gur, Ronen Zalts, Yaniv Dotan, Khitam Hussain, Ami Neuberger, Eyal Fuchs; Acute Crit Care. 2023;38(4):435-441. Published online November 23, 2023; DOI: https://doi.org/10.4266/acc.2023.00451

11,894 View
154 Download
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Abstract PDF Supplementary Material: Background
Concerns regarding positive-pressure-ventilation for the treatment of coronavirus disease 2019 (COVID-19) hypoxemia led the search for alternative oxygenation techniques. This study aimed to assess one such method, dual oxygenation, i.e., the addition of a reservoir mask (RM) on top of a high-flow nasal cannula (HFNC).
Methods
In this retrospective cohort study, the records of all patients hospitalized with COVID-19 during 2020–2022 were reviewed. Patients over the age of 18 years with hypoxemia necessitating HFNC were included. Exclusion criteria were positive-pressure-ventilation for any indication other than hypoxemic respiratory failure, transfer to another facility while still on HFNC and “do-not-intubate/resuscitate” orders. The primary outcome was mortality within 30 days from the first application of HFNC. Secondary outcomes were intubation and admission to the intensive care unit.
Results
Of 659 patients included in the final analysis, 316 were treated with dual oxygenation and 343 with HFNC alone. Propensity for treatment was estimated based on background diagnoses, laboratories and vital signs upon admission, gender and glucocorticoid dose. Inverse probability of treatment weighted regression including age, body mass index, Sequential Organ Failure Assessment (SOFA) score and respiratory rate oxygenation index showed treatment with dual oxygenation to be associated with lower 30-day mortality (adjusted hazard ratio, 0.615; 95% confidence interval, 0.469–0.809). Differences in the secondary outcomes did not reach statistical significance.
Conclusions
Our study suggests that the addition of RM on top of HFNC may be associated with decreased mortality in patients with severe COVID-19 hypoxemia.

Pulmonary
Comparison of high-flow nasal oxygen therapy and noninvasive ventilation in COVID-19 patients: a systematic review and meta-analysis: Glenardi Glenardi, Febie Chriestya, Bambang J Oetoro, Ghea Mangkuliguna, Natalia Natalia; Acute Crit Care. 2022;37(1):71-83. Published online February 22, 2022; DOI: https://doi.org/10.4266/acc.2021.01326

20,580 View
573 Download
12 Web of Science
11 Crossref

Abstract PDF Supplementary Material

Background
Acute respiratory failure (ARF) is a major adverse event commonly encountered in severe coronavirus disease 2019 (COVID-19). Although noninvasive mechanical ventilation (NIV) has long been used in the management of ARF, it has several adverse events which may cause patient discomfort and lead to treatment complication. Recently, high-flow nasal cannula (HFNC) has the potential to be an alternative for NIV in adults with ARF, including COVID-19 patients. The objective was to investigate the efficacy of HFNC compared to NIV in COVID-19 patients.
Methods
This meta-analysis was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. Literature search was carried out in electronic databases for relevant articles published prior to June 2021. The protocol used in this study has been registered in International Prospective Register of Systematic Reviews (CRD42020225186).
Results
Although the success rate of NIV is higher compared to HFNC (odds ratio [OR], 0.39; 95% confidence interval [CI], 0.16–0.97; P=0.04), this study showed that the mortality in the NIV group is also significantly higher compared to HFNC group (OR, 0.49; 95% CI, 0.39–0.63; P<0.001). Moreover, this study also demonstrated that there was no significant difference in intubation rates between the two groups (OR, 1.35; 95% CI, 0.86–2.11; P=0.19).
Conclusions
Patients treated with HFNC showed better outcomes compared to NIV for ARF due to COVID-19. Therefore, HFNC should be considered prior to NIV in COVID-19–associated ARF. However, further studies with larger sample sizes are still needed to better elucidate the benefit of HFNC in COVID-19 patients.

Citations

Citations to this article as recorded by

Comparison of high-flow nasal cannula and noninvasive ventilation in COVID-19-related hypoxemic respiratory failure: a retrospective observational study
Ahmed Saied Abdelmohsen, Mahmoud Mohamed Emam, Khaled M. Taema, Hossam Hosni Masoud, Soliman Belal
The Egyptian Journal of Critical Care Medicine.2026;[Epub] CrossRef
Trends and management of acute respiratory failure in hospitalized patients: a multicenter retrospective study in South Korea
Won Jin Yang, Yong Jun Choi, Kyung Soo Chung, Ji Soo Choi, Bo Mi Jung, Jae Hwa Cho
Acute and Critical Care.2025; 40(2): 171. CrossRef
2023 Year in Review: High-Flow Nasal Cannula for COVID-19
Michael D Davis
Respiratory Care.2024; 69(12): 1587. CrossRef
High-flow nasal cannula therapy in patients with COVID-19 in intensive care units in a country with limited resources: a single-center experience
Anh-Minh Vu Phan, Hai-Yen Thi Hoang, Thanh-Son Truong Do, Trung Quoc Hoang, Thuan Van Phan, Nguyet-Anh Phuong Huynh, Khoi Minh Le
Journal of International Medical Research.2023;[Epub] CrossRef
Evaluating the use of the respiratory-rate oxygenation index as a predictor of high-flow nasal cannula oxygen failure in COVID-19
Scott Weerasuriya, Savvas Vlachos, Ahmed Bobo, Namitha Birur Jayaprabhu, Lauren Matthews, Adam R Blackstock, Victoria Metaxa
Acute and Critical Care.2023; 38(1): 31. CrossRef
Does the variant positivity and negativity affect the clinical course in COVID-19?: A cohort study
Erkan Yildirim, Levent Kilickan, Suleyman Hilmi Aksoy, Ramazan Gozukucuk, Hasan Huseyin Kilic, Yakup Tomak, Orhan Dalkilic, Ibrahim Halil Tanboga, Fevzi Duhan Berkan Kilickan
Medicine.2023; 102(9): e33132. CrossRef
The COVID-19 Driving Force: How It Shaped the Evidence of Non-Invasive Respiratory Support
Yorschua Jalil, Martina Ferioli, Martin Dres
Journal of Clinical Medicine.2023; 12(10): 3486. CrossRef
Descriptive account of the first use of the LeVe CPAP System, a new frugal CPAP System, in adult patients with COVID-19 Pneumonitis in Uganda
Anna Littlejohns, Helen Please, Racheal Musasizi, Stuart Murdoch, Gorret Nampiina, Ian Waters, William Davis Birch, Gregory de Boer, Nikil Kapur, Tumwesigye Ambrozi, Ninsiima Carol, Nakigudde Noel, Jiten Parmar, Peter Culmer, Tom Lawton, Edith Namulema
Tropical Medicine and Health.2023;[Epub] CrossRef
Mechanical ventilation and outcomes in COVID-19 patients admitted to intensive care unit in a low-resources setting: A retrospective study
Sarakawabalo Assenouwe, Tabana Essohanam Mouzou, Ernest Ahounou, Lidaw Déassoua Bawe, Awèréou Kotosso, Koffi Atsu Aziagbe, Eyram Makafui Yoan Amekoudi, Mamoudou Omourou, Chimene Etonga Anoudem, Komi Séraphin Adjoh
Journal of Acute Disease.2023; 12(5): 186. CrossRef
Comparison between high-flow nasal cannula and noninvasive ventilation in COVID-19 patients: a systematic review and meta-analysis
Yun Peng, Bing Dai, Hong-wen Zhao, Wei Wang, Jian Kang, Hai-jia Hou, Wei Tan
Therapeutic Advances in Respiratory Disease.2022;[Epub] CrossRef
Does High Flow Nasal Cannula avoid intubation and improve the mortality of adult patients in acute respiratory failure in the intensive care setting, when compared to others methods as Conventional Oxygen Therapy or Non-Invasive Ventilation? A narrative r
P Fosseur, A Renard, P Mateu, J Rosman
Acta Anaesthesiologica Belgica.2022; 73(Supplement): 97. CrossRef

Pulmonary
Protecting Postextubation Respiratory Failure and Reintubation by High-Flow Nasal Cannula Compared to Low-Flow Oxygen System: Single Center Retrospective Study and Literature Review: Minhyeok Lee, Ji Hye Kim, In Beom Jeong, Ji Woong Son, Moon Jun Na, Sun Jung Kwon; Acute Crit Care. 2019;34(1):60-70. Published online February 28, 2019; DOI: https://doi.org/10.4266/acc.2018.00311

13,261 View
233 Download
6 Web of Science
5 Crossref

Abstract PDF Supplementary Material

Background
Use of a high-flow nasal cannula (HFNC) reduced postextubation respiratory failure (PERF) and reintubation rate compared to use of a low-flow oxygen system (LFOS) in low-risk patients. However, no obvious conclusion was reached for high-risk patients. Here, we sought to present the current status of HFNC use as adjunctive oxygen therapy in a clinical setting and to elucidate the nature of the protective effect following extubation.
Methods
The medical records of 855 patients who were admitted to the intensive care unit of single university hospital during a period of 5.5 years were analyzed retrospectively, with only 118 patients ultimately included in the present research. The baseline characteristics of these patients and the occurrence of PERF and reintubation along with physiologic changes were analyzed.
Results
Eighty-four patients underwent HFNC, and the remaining 34 patients underwent conventional LFOS after extubation. Physicians preferred HFNC to LFOS in the face of highrisk features including old age, neurologic disease, moderate to severe chronic obstructive pulmonary disease, a long duration of mechanical ventilation, low baseline arterial partial pressure of oxygen to fraction of inspired oxygen ratio, and a high baseline alveolar–arterial oxygen difference. The reintubation rate at 72 hours after extubation was not different (9.5% vs. 8.8%; P=1.000). Hypoxic respiratory failure was slightly higher in the nonreintubation group than in the reintubation group (31.9% vs. 6.7%; P=0.058). Regarding physiologic effects, heart rate was only stabilized after 24 hours of extubation in the HFNC group.
Conclusions
No difference was found in the occurrence of PERF and reintubation between both groups. It is worth noting that similar PERF and reintubation ratios were shown in the HFNC group in those with certain exacerbating risk factors versus not. Caution is needed regarding delayed reintubation in the HFNC group.

Citations

Citations to this article as recorded by

High-flow nasal therapy vs conventional oxygen therapy in mild COVID-19 hypoxaemia: a Bayesian reanalysis of the COVID-HIGH Trial
Claudia Crimi, Salvatore Sardo, Alberto Noto, Fabiana Madotto, Mariachiara Ippolito, Santi Nolasco, Raffaele Campisi, Giuseppe Fiorentino, Ioannis Pantazopoulos, Athanasios Chalkias, Alessio Mattei, Raffaele Scala, Enrico Clini, Begum Ergan, Manel Lujan,
Journal of Anesthesia, Analgesia and Critical Care.2026;[Epub] CrossRef
Comparison of ROX index with modified indices incorporating heart rate, flow rate, and PaO2/FiO2 ratio for early prediction of outcomes among patients initiated on post-extubation high-flow nasal cannula therapy
Smitesh Gutta, Wei Jun Dan Ong, Shanaz Matthew Sajeed, Belinda Zer Hui Chern, Monika Gulati Kansal, Faheem Ahmed Khan, Amit Kansal
European Journal of Medical Research.2025;[Epub] CrossRef
High-flow nasal oxygen therapy compared with conventional oxygen therapy in hospitalised patients with respiratory illness: a systematic review and meta-analysis
Daniel Seow, Yet H Khor, Su-Wei Khung, David M Smallwood, Yvonne Ng, Amy Pascoe, Natasha Smallwood
BMJ Open Respiratory Research.2024; 11(1): e002342. CrossRef
Predictors and outcomes of high-flow nasal cannula failure following extubation: A multicentre observational study
Amit Kansal, Shekhar Dhanvijay, Andrew Li, Jason Phua, Matthew Edward Cove, Wei Jun Dan Ong, Ser Hon Puah, Vicky Ng, Qiao Li Tan, Julipie Sumampong Manalansan, Michael Sharey Nocon Zamora, Michael Camba Vidanes, Juliet Tolentino Sahagun, Juvel Taculod, Ad
Annals of the Academy of Medicine, Singapore.2021; 50(6): 467. CrossRef
Flow Field Analysis of Adult High‐Flow Nasal Cannula Oxygen Therapy
Jingen Xia, Jiaqi Chang, Jixiang Liang, Yixuan Wang, Na Wang, Bo Xiao
Complexity.2021;[Epub] CrossRef

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