Effect of high-flow nasal cannula therapy versus continuous positive airway pressure

What is the ideal first-line mode of non-invasive respiratory support in acutely unwell children with respiratory failure? High flow nasal flow cannula (HFNC) therapy is being used frequently in intensive care units and on the inpatient wards and emergency departments. How does it compare to continuous positive airway pressure (CPAP)? Ramnarayan P et al (JAMA 2022 doi:10.1001/jama.2022.9615) have completed an elegant study evaluating the noninferiority of high-flow nasal cannula therapy (HFNC) as the first-line mode of noninvasive respiratory support for acute illness, compared with continuous positive airway pressure (CPAP), for time to liberation from all forms of respiratory support. This is a pragmatic, multicentre, randomised noninferiority clinical trial conducted in 24 paediatric critical care units in the United Kingdom among 600 acutely ill children aged 0 to 15 years who were clinically assessed to require noninvasive respiratory support. They were randomised 1:1 to commence either HFNC at a flow rate based on patient weight (n=301) or CPAP of 7 to 8 cm H2O (n=299). Of the 600 randomised children, 573 children (HFNC: 295; CPAP: 278) were included in the primary analysis (median age, 9 months; 226 girls [39%]). The median time to liberation in the HFNC group was 52.9 hours (95% CI, 46.0 to 60.9 hours) vs 47.9 hours …