Comparison of the Heated Humidified High-flow Nasal Cannula with Nasal Continuous Positive Airway Pressure as Primary Respiratory Support for Preterm Neonates: A Prospective Observational Study

Document Type : Original Article


1 Department of Respiratory Therapy, School of Allied Health Science, Manipal Academy of Higher Education, Manipal, Karnataka, India

2 Hamad Medical Corporation, Qatar

3 Department of Pediatrics, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India


Background: Heated humidified high-flow nasal cannula (HHHFNC) is gaining popularity in the management of respiratory distress in preterm neonates. However, it is not known whether it takes precedence over the gold standard nasal continuous positive airway pressure (NCPAP) in this age group as a primary mode of non-invasive ventilation (NIV). There is limited evidence addressing this issue in the literature. Therefore, this study aimed to focus on the effect of HHHFNC on preterm neonates with respiratory distress, compared to NCPAP as a primary mode of respiratory support.
Methods: A prospective observational study conducted in tertiary level III NICU. The preterm neonates 28-36 weeks with respiratory distress syndrome (onset of distress within ≤4 hours of life with FiO2 ≥0.25 with compatible chest radiograph) were managed with either HHHFNC or nCPAP The need for invasive ventilation within 72 hours of initiation of non-invasive respiratory support was studied. FiO2 and Downe’s scores were recorded every 4th hour for the first 48 hours.
Results: In total, 84 neonates were enrolled in this study. Treatment failure for HHHFNC group was 34.4%, whereas it was 32.2% (P=0.34) for NCPAP group which indicated no significant differences. In the late preterm strata, NCPAP group obtained longer duration for NIV (Median: 64 vs 43 hours, respectively; P<0.001); however, there were no differences between the study groups regarding the use of supplemental oxygen. The estimation of the survival time was plotted using the Kaplan-Meier curve (P<0.001). In addition, the two groups were compared through Gehan–Breslow–Wilcoxon test. Moreover, the results revealed differences between the two groups in terms of the hazards ratio for time to success regarding such items as the intervention group, gestational age, birth weight, surfactant therapy, and Downe’s score (1.17; CI: 95% [0.7, 1.8]).
Conclusion: Early HHHFNC obtained similar results, compared to NCPAP as a primary mode of NIV for a preterm population with respiratory distress, and it may not be superior to NCPAP.


1. Diblasi RM. Neonatal noninvasive ventilation techniques: do we really need to intubate? Respir Care. 2011; 56(9):1273-94.
2. Diblasi RM. Nasal continuous positive airway pressure (CPAP) for the respiratory care of the newborn infant. Respir Care. 2009; 54(9):1209-35.
3. Dysart K, Miller TL, Wolfson MR, Shaffer TH. Research in high flow therapy: mechanisms of action. Respir Med. 2009; 103(10):1400-5.
4. Saslow JG, Aghai ZH, Nakhla TA, Hart JJ, Lawrysh R, Stahl GE, et al. Work of breathing using high-flow nasal cannula in preterm infants. J Perinatol. 2006; 26(8):476-80.
 5. 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. J Perinatol. 2007; 27(12):772-5.
 6. 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(5):1081-3.
 7. Waugh JB, Granger WM. An evaluation of 2 new devices for nasal high-flow gas therapy. Respir Care. 2004; 49(8):902-6.
 8. Woodhead DD, Lambert DK, Clark JM, Christensen RD. Comparing two methods of delivering high-flow gas therapy by nasal cannula following endotracheal extubation: a prospective, randomized, masked, crossover trial. J Perinatol. 2006; 26(8):481-5.
9. Kopelman AE, Holbert D. Use of oxygen cannulas in extremely low birthweight infants is associated with mucosal trauma and bleeding, and possibly with coagulase-negative staphylococcal sepsis. J Perinatal. 2003; 23(2):94-7.
10. Ojha S, Gridley E, Dorling J. Use of heated humidified high-flow nasal cannula oxygen in neonates: a UK wide survey. Acta Paediatr. 2013; 102(3):249-53.
11. Yoder BA, Stoddard RA, Li M, King J, Dirnberger DR, Abbasi S. Heated, humidified high-flow nasal cannula versus nasal CPAP for respiratory support in neonates. Pediatrics. 2013; 131(5):e1482-90. 12. Roberts CT, Owen LS, Manley BJ, Frøisland DH, Donath SM, Dalziel KM, et al. Nasal high-flow therapy for primary respiratory support in preterm infants. New Engl J Med. 2016; 375(12):1142-51. 13. Manley BJ, Roberts CT, Frøisland DH, Doyle LW, Davis PG, Owen LS. Refining the use of nasal highflow therapy as primary respiratory support for preterm infants. J Pediatr. 2018; 196:65-70 .
14. Manley BJ, Owen LS, Doyle LW, Andersen CC, Cartwright DW, Pritchard MA, et al. High-flow nasal cannulae in very preterm infants after extubation. N Engl J Med. 2013; 369(15):1425-33.
 15. Campbell DM, Shah PS, Shah V, Kelly EN. Nasal continuous positive airway pressure from high flow cannula versus Infant Flow for Preterm infants. J Perinatol. 2006; 26(9):546-9.
16. Wilkinson D, Andersen C, O’Donnell CP, De Paoli AG. High flow nasal cannula for respiratory support in preterm infants. Cochrane Database Syst Rev. 2011; 5:CD006405.
17. Chakravarthy Konda K, Edward Lewis L, Ramesh Bhat Y, Purkayastha J, Kanaparthi S. Heated humidified high-flow nasal cannula versus nasal continuous positive airway pressure for the facilitation of extubation in preterm neonates with respiratory distress. Iran J Neonatol. 2018; 9(2): 14-20.
18. Holleman-Duray D, Kaupie D, Weiss MG. Heated humidified high-flow nasal cannula: use and a neonatal early extubation protocol. J Perinatol. 2007; 27(12):776-81.
 19. Lampland AL, Plumm B, Meyers PA, Worwa CT, Mammel MC. Observational study of humidified high-flow nasal cannula compared with nasal continuous positive airway pressure. J Pediatr. 2009; 154(2):177-82.