Nasal High Flow for Neonates

Evidence-based applications of NHF for neonates

Data from large randomized controlled trials and a Cochrane Review suggest three possible pathways to introduce NHF for neonates 28 weeks of gestational age or older^1-7:

Post extubation
An alternative to prolonged continuous positive airway pressure (CPAP)
Primary support.

This information collates data from published literature. It does not overrule expert clinical judgement. Gestational age alone should not determine individual patient management.


	NHF for postextubation support Learn more

	NHF as an alternative to prolonged CPAP Learn more

	NHF as primary support Learn more

Clinical judgement is necessary to assess the apropriate treatment for an individual patient.

NHF as postextubation support

For stable neonatal patients who are 28 weeks gestational age or older, there is well-established evidence supporting the use of NHF for postextubation support as a suitable alternative to CPAP.⁴^–^6,8

A Cochrane Review by Wilkinson et al. indicates that the use of NHF instead of CPAP is associated with significantly lower rates of nasal trauma, with no additional risk of treatment failure, reintubation, or adverse events such as death, pneumothorax or bronchopulmonary dysplasia (BPD).⁵A clinical pathway involving an escalation step to CPAP if required may also be appropriate⁸.

For neonates under 28 weeks’ gestational age, there is insufficient evidence to change clinical practice and CPAP continues to be the gold standard of care for postextubation support.⁵ Once the patient is stable, NHF can be considered to help facilitate developmental care and reduce nasal trauma.^7,9

This information collates data from published literature. It does not overrule expert clinical judgement. Gestational age alone should not determine individual patient management.

NHF as an alternative to prolonged CPAP

Expert consensus suggests that NHF may be a suitable alternative to CPAP, for neonates who require prolonged periods of noninvasive support.^1,2

Once neonatal patients are stable on CPAP, NHF may be considered as an alternative noninvasive therapy at the clinician’s discretion.^1,2

NHF as primary support

Comparing the safety and efficacy of NHF and CPAP for initial respiratory support, several studies from around the globe indicate that neonates who are 28 weeks gestational age or older can be treated with either NHF or CPAP first, with no significant difference in intubation rates.^3,4,10-12

If NHF is used first, a clinical pathway involving an escalation step to CPAP if required may also be appropriate.⁸

For neonates of a gestational age of under 28 weeks, there is insufficient evidence to change clinical practice and CPAP should be used as primary support.^7,9 Once the patient is stable, NHF can be considered to help facilitate developmental care and reduce nasal trauma.^7,9

This information collates data from published literature. It does not overrule expert clinical judgement. Gestational age alone should not determine individual patient management.

Setting flow rates for neonates

NHF is a mode of noninvasive respiratory support that delivers high flows of blended air and oxygen through a nasal cannula. Guidance from the neonatal literature and from expert consensus indicates that flow rates should be initiated between 4 and 6 L/min.^4,6-8,10

Download the clinical summary book

The Rosie Hospital NHF Documentary Series

The reason, the rollout and the results: The Rosie Hospital, a Cambridge University Hospital, shares its successful implementation of NHF therapy for neonatal patients.

NHF in practice at the Rosie Hospital

Learn how the Rosie Hospital in the UK uses NHF therapy in the unit

The impact of a new therapy at the Rosie

The impact of NHF therapy at the Rosie Hospital

Discover the hospital’s journey of successfully implementing NHF therapy

The implementation of a new therapy at the Rosie

Implementation of NHF at the Rosie Hospital

Explore the research behind the decision to implement NHF at the Rosie Hospital.

Wilkinson, D., Andersen, C., O’Donnell, C. P. F., De Paoli, A. G., & Manley, B. J. High flow nasal cannula for respiratory support in preterm infants. Cochrane Database Syst. Rev. 2, CD006405 (2016).  View abstract here.
Collins, C. L., Holberton, J. R. J., Barfield, C., & Davis, P. G. P. A randomized controlled trial to compare heated humidified high-flow nasal cannulae with nasal continuous positive airway pressure postextubation in premature infants. J. Pediatr. 162, 949–954.e1 (2013).  View abstract here.
Roberts, C. et al. Nasal high-flow therapy for primary respiratory support in preterm infants. N. Engl. J. Med. 375, 1142–1151 (2016).  View abstract here.
Yoder, B. et al. Heated, humidified high-flow nasal cannula versus nasal CPAP for respiratory support in neonates. Pediatrics 131, e1482–1490 (2013). View abstract here.
Roehr, C. C., Yoder, B. A., Davis, P. G., & Ives, K. Evidence support and guidelines for using heated, humidified, high-flow nasal cannulae in neonatology: Oxford Nasal High-Flow Therapy Meeting, 2015. Clin. Perinatol. 43, 693–705 (2016).  View abstract here.
Roberts, C. & Hodgson, K. Nasal high-flow treatment in preterm infants. Matern. Heal. Neonatol. Perinatol. 3, 15 (2017).  View abstract here.
Yoder, B. et al. Heated, humidified high-flow nasal cannula versus nasal CPAP for respiratory support in neonates. Pediatrics 131, e1482–1490 (2013).  View abstract here.
Manley, B. et al. High-flow nasal cannulae in very preterm infants after extubation. N. Engl. J. Med. 369, 1425–1433 (2013). View abstract here. 
Manley, B. Nasal high-flow therapy for preterm infants: review of neonatal trial data. Clin. Perinatol. 43, 673–691 (2016).  View abstract here.
Lavizzari, A. et al. Heated, humidified high-flow nasal cannula vs nasal continuous positive airway pressure for respiratory distress syndrome of prematurity: a randomized clinical noninferiority trial. JAMA Pediatr. (2016). doi:10.1001/jamapediatrics.2016.1243.  View abstract here.
Shin, J., Park, K., Lee, E., & Choi, B. Humidified high-flow nasal cannula versus nasal continuous positive airway pressure as an initial respiratory support in preterm infants with respiratory distress: a randomized, controlled noninferiority trial. J. Korean Med. Sci. 32, 650–655 (2017). View abstract here.
Murki, S. et al. High-flow nasal cannula versus nasal continuous positive airway pressure for primary respiratory support in preterm infants with respiratory distress: a randomized controlled trial. Neonatology 113, 235–241 (2018). View abstract here.