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High-Flow Nasal Cannula Is a Safe Alternative to CPAP in Preterm Infants With Respiratory Distress


  • In preterm neonates with respiratory distress, does high-flow nasal cannula provide a safe and efficacious alternative to nasal CPAP?

Clinical Bottom Lines

  1. Preterm neonates less than 30 weeks’ gestation may benefit from a trial of high-flow nasal cannula (HFNC) in place of nasal CPAP for treatment of respiratory distress.
  2. The study below suggests that there is no significant difference in incidence of pneumothorax or development of BPD between infants placed on NCPAP vs. HFNC, and that HFNC is strongly associated with a lower rate of intubation compared with NCPAP.

Summary of Key Evidence

  1. A retrospective, historical comparison study1 was performed on 101 neonates < 30 weeks' gestation admitted to two Level III NICUs over a one-year period before (Era 1) or after (Era 2) June 2004.  36 neonates admitted during Era 1 who had undergone NCPAP therapy within 96 hours of birth formed the "historical control" group.  65 neonates admitted during Era 2 who had undergone HFNC therapy within 96 hours of birth formed the comparison group.
  2. Exclusion criteria included major congenital malformations, chromosomal abnormalities, and genetic syndromes.
  3. Baseline characteristics of infants were not found to differ between groups with respect to gestational age, birth weight, sex, race, maternal betamethasone administration, mode of delivery, surfactant administration, initial mode of respiratory support, and time to extubation if mechanical ventilation was used first.
  4. There was no significant difference between groups in rates of death (p=1), pneumothorax (p=1), IVH > Grade II (p=0.66), PDA (p=0.79), NEC (p=0.53), BPD (p=0.47), infection (p=0.82), or ROP (p=0.26).
  5. There was a significant difference between groups in rate of (re)intubation (p=0.03) with over twice the rate of intubation among infants in the NCPAP group (40%) as in the HFNC group (18%).

Additional Comments

  • HFNC and NCPAP are mechanistically similar modes of therapy.  The PEEP generated by HFNC at a given flow rate depends on the weight of the infant and the size of the nasal prongs used.2,3
  • HFNC has been shown to be an effective alternative to NCPAP in the treatment of apnea of prematurity,3 but very little research has been published examining HFNC vs. NCPAP in the treatment of neonatal respiratory distress.4


  1. Shoemaker MT, Pierce MR, Yoder BA, DiGeronimo RJ. High flow nasal cannula versus nasal CPAP for neonatal respiratory disease: a retrospective study. Journal of Perinatology 2007;27:85-91.
  2. Spence KL, Murphy D, Kilian C, McGonigle R, Kilani RA. High-flow nasal cannula as a device to provide continuous positive airway pressure in infants. Journal of Perinatology 2007;27:1-4.
  3. Sreenan C, Lemke RP, Hudson-Mason A, Osiovich H. High-flow nasal cannulae in the management of apnea of prematurity: A comparison with conventional nasal continuous positive airway pressure. Pediatrics 2001;107:1081-3.
  4. Campbell DM, Shah PS, Shah V, Kelly EN. Nasal continuous positive airway pressure from high flow cannula versus Infant Flow for preterm infants. Journal of Perinatology 2006;26:546-9.

CAT Author: Mien Chyi, MD

CAT Appraisers: James Gurney, PhD

Date appraised: October 24, 2007

Last updated October 29, 2008
Department of Pediatrics and Communicable Diseases
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