Authors: Park J-B et al.
Anesthesiology, March 13, 2026, 10.1097/ALN.0000000000005946
This randomized controlled trial evaluated whether high-flow nasal oxygenation (HFNO) improves oxygenation and intubation outcomes in infants compared with conventional face mask ventilation. HFNO has become increasingly popular for preoxygenation and apneic oxygenation in adults and older children, but evidence in infants remains limited due to their unique airway physiology, high oxygen consumption, and rapid desaturation risk.
The investigators conducted a prospective, single-center randomized trial including 132 infants scheduled for elective surgery requiring tracheal intubation. Infants were randomized to receive either HFNO or conventional face mask ventilation during preoxygenation and the intubation process.
In the HFNO group, infants received high-flow nasal oxygen at 0.5 L/kg/min for three minutes during preoxygenation. Oxygen delivery was then increased to 2 L/kg/min during the apneic period and maintained during laryngoscopy. In the control group, infants received conventional face mask preoxygenation at 6 L/min for three minutes, followed by face mask ventilation during the apneic period, but no oxygen delivery during laryngoscopy.
The primary outcome was the incidence of oxygen desaturation, defined as peripheral oxygen saturation below 95% lasting at least five seconds between the start of preoxygenation and one minute after intubation.
After exclusions, 125 infants were included in the final analysis. The incidence of oxygen desaturation did not differ significantly between groups. Desaturation occurred in 13.3% of infants in the HFNO group compared with 9.2% in the face mask ventilation group. This difference was not statistically significant.
Secondary outcomes also showed no meaningful differences between the groups. The incidence of more severe desaturation below 90%, first-attempt intubation success rates, lowest oxygen saturation during the procedure, and post-intubation end-tidal gas measurements were similar. Radiologic atelectasis scores were also comparable.
However, one important difference was observed. Gastric insufflation occurred significantly less frequently in the HFNO group compared with the face mask group. Approximately 37% of infants receiving HFNO had evidence of gastric insufflation compared with about 71% in the control group. This reduction likely reflects the absence of positive-pressure mask ventilation in the HFNO technique.
The authors conclude that HFNO did not significantly reduce desaturation during intubation compared with conventional face mask ventilation in this infant population. Nevertheless, the technique may offer advantages by reducing gastric insufflation, which could theoretically lower the risk of aspiration and abdominal distension.
What You Should Know
Infants have high oxygen consumption and limited oxygen reserves, making desaturation during airway management common.
High-flow nasal oxygenation has gained popularity as a method of preoxygenation and apneic oxygenation, but its benefits in infants remain uncertain.
This randomized trial found no improvement in oxygen saturation outcomes with HFNO compared with traditional face mask ventilation.
However, HFNO significantly reduced gastric insufflation during airway management.
The findings suggest that HFNO may offer physiologic advantages even if it does not reduce desaturation risk in routine infant intubation.
Key Points
Randomized controlled trial including 125 infants undergoing elective intubation.
HFNO did not reduce the incidence of desaturation below 95% compared with face mask ventilation.
Rates of severe desaturation below 90% and first-attempt intubation success were similar between groups.
Gastric insufflation occurred significantly less frequently with HFNO.
HFNO may provide a useful alternative airway management strategy but did not improve oxygenation outcomes in this study.
Thank you to Anesthesiology for allowing us to summarize this article.