Clinical Review| Volume 57, ISSUE 3, P322-328, September 2019

Download started.


High Flow Nasal Cannula Oxygen vs. Conventional Oxygen Therapy and Noninvasive Ventilation in Emergency Department Patients: A Systematic Review and Meta-Analysis



      Acute respiratory failure (ARF) is a common cause of presentation to the Emergency Department (ED). High flow nasal cannula (HFNC) has been introduced as an alternative way to administer oxygen.


      We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing HFNC with conventional oxygen therapy (COT) and noninvasive ventilation (NIV) exclusively in the ED setting.


      Inclusion criteria were: RCTs on adults with ARF admitted to the ED, investigating HFNC vs. COT or other modes of ventilation. Trials that compared HFNC support outside the ED, were published as an abstract, or nonrandomized were excluded.


      Four RCTs comparing HFNC with COT and one HFNC to NIV met the criteria. Overall, 775 patients were included. The meta-analysis of the studies comparing HFNC and COT showed no differences in intubation requirement, treatment failure, hospitalization, or mortality. Intolerance was significantly higher with HFNC (risk ratio 6.81 95% confidence interval 1.18–39.19; p = 0.03). In the only available RCT comparing HFNC with NIV, no difference was found for intubation rate, treatment failure, tolerance, and dyspnea.


      We did not find any benefit of HFNC compared with COT and NIV in terms of intubation requirement, treatment failure, hospitalization, and mortality; COT was better tolerated.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Kallstrom T.J.
        American Association for Respiratory Care (AARC). AARC Clinical Practice Guideline: oxygen therapy for adults in the acute care facility--2002 revision & update.
        Respir Care. 2002; 47: 717-720
        • O'Driscoll B.R.
        • Howard L.S.
        • Davison A.G.
        • British Thoracic Society
        BTS guideline for emergency oxygen use in adult patients.
        Thorax. 2008; 63: vi1-vi68
        • Lenglet H.
        • Sztrymf B.
        • Leroy C.
        • Brun P.
        • Dreyfuss D.
        • Ricard J.D.
        Humidified high flow nasal oxygen during respiratory failure in the emergency department: feasibility and efficacy.
        Respir Care. 2012; 57: 1873-1878
        • Nishimura M.
        High-flow nasal cannula oxygen therapy in adults: physiological benefits, indication, clinical benefits, and adverse effects.
        Respir Care. 2016; 61: 529-541
        • Ricard J.D.
        High flow nasal oxygen in acute respiratory failure.
        Minerva Anestesiol. 2012; 78: 836-841
        • Masclans J.R.
        • Pérez-Terán P.
        • Roca O.
        The role of high flow oxygen therapy in acute respiratory failure.
        Med Intensiva. 2015; 39: 505-515
        • Ni Y.N.
        • Luo J.
        • Yu H.
        • et al.
        Can high-flow nasal cannula reduce the rate of endotracheal intubation in adult patients with acute respiratory failure compared with conventional oxygen therapy and noninvasive positive pressure ventilation?: a systematic review and meta-analysis.
        Chest. 2017; 151: 764-775
        • Lee C.C.
        • Mankodi D.
        • Shaharyar S.
        • et al.
        High flow nasal cannula versus conventional oxygen therapy and non-invasive ventilation in adults with acute hypoxemic respiratory failure: a systematic review.
        Respir Med. 2016; 121: 100-108
        • Leeies M.
        • Flynn E.
        • Turgeon A.F.
        • et al.
        High-flow oxygen via nasal cannulae in patients with acute hypoxemic respiratory failure: a systematic review and meta-analysis.
        Syst Rev. 2017; 6: 202
        • Zhao H.
        • Wang H.
        • Sun F.
        • Lyu S.
        • An Y.
        High-flow nasal cannula oxygen therapy is superior to conventional oxygen therapy but not to noninvasive mechanical ventilation on intubation rate: a systematic review and meta-analysis.
        Crit Care. 2017; 21: 184
        • Lin S.M.
        • Liu K.X.
        • Lin Z.H.
        • Lin P.H.
        Does high-flow nasal cannula oxygen improve outcome in acute hypoxemic respiratory failure? A systematic review and meta-analysis.
        Respir Med. 2017; 131: 58-64
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        • PRISMA Group
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        PLoS Med. 2009; 6: e1000097
        • Higgins J.P.
        • Altman D.G.
        • Gotzsche P.C.
        • et al.
        The Cochrane Collaboration's tool for assessing risk of bias in randomised trials.
        BMJ. 2011; 343: d5928
        • Jones P.G.
        • Kamona S.
        • Doran O.
        • Sawtell F.
        • Wilsher M.
        Randomized controlled trial of humidified high-flow nasal oxygen for acute respiratory distress in the emergency department: the HOT-ER Study.
        Respir Care. 2016; 61: 291-299
        • Makdee O.
        • Monsomboon A.
        • Surabenjawong U.
        • et al.
        High-flow nasal cannula versus conventional oxygen therapy in emergency department patients with cardiogenic pulmonary edema: a randomized controlled trial.
        Ann Emerg Med. 2017; 70: 465-472.e2
        • Bell N.
        • Hutchinson C.L.
        • Green T.C.
        • Rogan E.
        • Bein K.J.
        • Dinh M.M.
        Randomised control trial of humidified high flow nasal cannulae versus standard oxygen in the emergency department.
        Emerg Med Australas. 2015; 27: 537-541
        • Rittayamai N.
        • Tscheikuna J.
        • Praphruetkit N.
        • Kijpinyochai S.
        Use of high-flow nasal cannula for acute dyspnea and hypoxemia in the emergency department.
        Respir Care. 2015; 60: 1377-1382
        • Doshi P.
        • Whittle J.S.
        • Bublewicz M.
        • et al.
        High-velocity nasal insufflation in the treatment of respiratory failure: a randomized clinical trial.
        Ann Emerg Med. 2018; 72: 73-83.e5
        • Mauri T.
        • Galazzi A.
        • Binda F.
        • et al.
        Impact of flow and temperature on patient comfort during respiratory support by high-flow nasal cannula.
        Crit Care. 2018; 22: 120

      Linked Article