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Year : 2021  |  Volume : 5  |  Issue : 2  |  Page : 16-21

High-flow Nasal Cannula in Pediatric Patients

Department of Child-Health, Cipto Mangunkusumo Hospital, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia

Date of Submission05-Jan-2021
Date of Decision19-Mar-2021
Date of Acceptance27-Dec-2021
Date of Web Publication20-Jul-2022

Correspondence Address:
Niken W Puspaningtyas
Department of Child-Health, Cipto Mangunkusumo Hospital, Faculty of Medicine University of Indonesia, Jl. Salemba Raya No. 6, Jakarta
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/prcm.prcm_1_21

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High-flow nasal cannula (HFNC) provides conditioned high-flow oxygen through an open system with high pressure and high velocity. HFNC has been widely used in neonatal patients with comparable benefit to CPAP; however, the use in pediatric patients has not been well evaluated. In pediatric patients, a regular nasal cannula is widely used as oxygen therapy, but the flow provided is limited because the humidity is not optimal. While HFNC as noninvasive oxygen therapy can deliver heated, humidified gas, via nasal cannula. High-velocity HFNC makes oxygen-rich gases occupy the dead space of the nasopharynx, increasing FiO2, and improving alveolar ventilation. The use of HFNC in children begins with bronchiolitis patients, also considered effective in various respiratory disorders including cases of hypoxemic respiratory failure. HFNC has been shown to have a better patient tolerance, less nose damage, and less work for the staff than CPAP and noninvasive ventilators (NIV). HFNC can be used in the emergency department and even the patient ward, while CPAP and NIV require intensive care unit facility as it needs close monitoring. HFNC is considered safe with mild side effects such as epistaxis and skin irritation that have been reported. While serious side effects such as pneumothorax are rarely reported because open system HFNC can prevent a sudden increase in airway pressure.

Keywords: Continue positive airway pressure, high-flow nasal cannula, pediatric

How to cite this article:
Puspaningtyas NW, Dewi R, Pudjiadi AH. High-flow Nasal Cannula in Pediatric Patients. Pediatr Respirol Crit Care Med 2021;5:16-21

How to cite this URL:
Puspaningtyas NW, Dewi R, Pudjiadi AH. High-flow Nasal Cannula in Pediatric Patients. Pediatr Respirol Crit Care Med [serial online] 2021 [cited 2022 Oct 3];5:16-21. Available from: https://www.prccm.org/text.asp?2021/5/2/16/351527

  Introduction Top

A nasal cannula is widely used for oxygen therapy in pediatric patients. The fraction of inspired oxygen (FiO2) delivered via nasal cannula increases along with flow increment. However, the non-optimal air humidity limits the flow generated by regular nasal cannula.[1] A High-flow nasal cannula (HFNC) is a noninvasive oxygen therapy that delivers heated, humidified gas via nasal cannula. There is currently no defined flow limit to achieve high flow and high pressure. In neonates, a flow greater than 2 L/min is considered high flow, while in children a flow of 4–6 L/min is needed to generate high flow with a velocity ranging from 4–70 L/min.[1],[2] Previous studies support that HFNC is more superior to low-flow nasal cannula, and is comparable or even better than Continuous Positive Airway Pressure (CPAP). There are currently not many studies on HFNC use in pediatric patients.

  Types of Oxygen Therapy Top

Oxygen therapy can be in the form of low-flow, reservoir, and high-flow systems. The low-flow system uses a regular nasal cannula, the reservoir system uses regular masks and reservoir masks to obtain greater FiO2, while the high-flow system uses conditioned air. Unlike the low-flow system that can only deliver FiO2 of 24–40%, the high-flow system can deliver oxygen with flow and velocity greater than normal inspiratory flow, thus achieving FiO2 of 21–100%.[3],[4]

  Principle of High-Flow Nasal Cannula Top

Unlike CPAP (continuous positive airway pressure) or BiPAP (bilevel positive airway pressure), HFNC is an open system in which equipment does not cover more than 50% of the nostril. Also, in HFNC air is conditioned (heated and humidified) to enable the delivery of high flow and high velocity of oxygen exceeding the peak inspiratory flow.[1]

The use of HFNC can reduce respiratory effort through several mechanisms, including reducing airway resistance during inspiration, reducing nasopharyngeal dead space, providing conditioned air (warm and humidified), and providing various degree of positive inspiration and expiration pressure.[1],[5]

The use of HFNC with flow greater than normal allows oxygen-rich gas to bypass the area with high airway resistance (nostril up to nasal cavity), reducing breathing effort as more oxygen-rich gas reaches the lower respiratory tract. The high-velocity, oxygen-rich gas administered through HFNC also occupies the nasopharyngeal dead space, increases FiO2 in the next cycle, and improves alveolar ventilation. This is especially important in children as the extrathoracic anatomical dead space can reach 3 ml/kg in children, and will only reach an adult rate of 0.8 ml/kg by 6 years old.[1],[5]

Cold air damages respiratory mucosa and reduces lung compliance. In vitro study demonstrated even short-term exposure of air with low humidity caused dysfunction of respiratory epithelial. Humidified and warmed gas in HFNC are not only able to reduce insensible water loss and energy consumption, but also can reduce mucus production and improve mucociliary clearance.[2]

High-flow nasal cannula can apply positive pressure to the respiratory system. HFNC creates positive pressure variation on the pharynx (preventing pharyngeal collapse) and auto-positive end-expiratory pressure (auto-PEEP). Auto-PEEP reduces inspirational requirements and facilitates inspiratory flow. Positive end-expiratory pressure has a stenting effect, preventing the collapse of the small airway and extending expiration time [Figure 1].[1],[2],[5],[6]
Figure 1: Physiological effects of high-flow nasal cannula (HFNC). During inspiration, HFNC reduces respiratory distress though fulfilling increased inspiratory flow demand through high flow, greater than patient’s requirement. During expiration, patient feels positive airway pressure, preventing pulmonary collapse[6]

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Milési et al. measured pharyngeal pressure under HFNC in 21 patients (aged under 6 months, an average body weight of 4.3 kg) with respiratory distress. He reported amount of flow is associated with pressure generated in the pharyngeal cavity. Flow ≥2 L/kg/min generates pharyngeal pressure ≥4 cmH2O. Pharyngeal pressure >6 L/min generates positive pressure upon both inspiration and expiration.[5],[6]

The flow entrained by HFNC depends on the cannula diameter. The flow starts from 0.5 L/kg/min and can be increased up to 2 L/kg/min. Flow greater than 2 L/kg/min does not confer additional benefit for pediatric patients.

  Basic Components of High-Flow Nasal Cannula System Top

Principally, HFNC components are made of a pressurized oxygen generator, flow meter, or blender that regulates outflow, sterile gas reservoir attached to heater and humidifier, a circuit to distribute conditioned gas, and cannula connected to the patient [Figure 2].[1]
Figure 2: High-flow nasal cannula components made of equipment from intensive care room[1]

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  Clinical Application Top

Three important variables to regulate in HFNC are temperature, FiO2, and flow. Temperature is set 1–2°C lower than normal body temperature for comfort.[1],[2] FiO2 setting depends on the patient’s clinical condition. In hypoxemia patients, FiO2 of HFNC is set at 60% that can be adjusted to achieve a target saturation of 92–97%. Patients without hypoxemia also benefit from conditioned air without additional FiO2. Flow is determined by the patient’s size, usually starting from 0.5–1 L/kg/min, and can be increased up to 2 L/kg/min.[1],[2],[5]

  Indications and Contraindications of High-Flow Nasal Cannula Top

Initially, HFNC is widely used in neonates. The use in pediatric patients started in bronchiolitis patients, due to sub-optimal symptoms reduction by medicamentosa.[1],[2] In various respiratory distress and even in respiratory failure cases HFNC is deemed effective. General indications for HFNC use are dyspnea, both primer or secondary to postextubation acute respiratory insufficiency (ARI), and even respiratory failure [Table 1].
Table 1: Indication of HFNC[9]

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Since 2010, HFNC use has been common in the intensive care setting, emergency room, and even pediatric wards for dyspnea caused by a disturbance in oxygenation and ventilation due to pneumonia, congestive heart failure, asthma, croup, wheezing induced by a viral infection, neuromuscular diseases, stridor due to postextubation, and obstructive sleep apnea (OSA).[7],[8]

Adapted from Spoletini with modifications[9]

Existing data support the use of HFNC in the oxygenation problem. A study by Oto et al. involved pediatric patients under 17 years old with type I respiratory failure (hypoxemia with PO2 <55 mmHg) showed significant improvement in respiratory rate (P = 0.032) and heart rate (P = 0.03) within 30 minutes following equipment of HFNC. Improvement was also seen for PO2 (80.36 + 34.87 mmHg, P = 0.569).[10] Another study conducted by Corley et al. involving 18 years old subjects with decreased PaO2/FiO2 (<300, baseline average of 160) following heart surgery showed that HFNC was able to increase PaO2/FiO2, mean airway pressure (MAP), and end-expiratory lung impedance (EELI) significantly.[11] The use of HFNC is contraindicated in cases such as pneumothorax, apnea, and orofacial abnormality.

  Benefits of High-Flow Nasal Cannula Top

The pressure generated from HFNC is affected by flow, the ratio between the nasal cannula and nostril diameter, and leakage from an open mouth. Therefore there is a high variation between individuals with HFNC.[7] As measuring pressure reaching the distal airway is challenging, the clinical response should be observed with HFNC use. Objective parameters include heart rate, respiratory rate, oxygen saturation level, and respiratory distress symptoms such as nasal flaring, and chest retraction.

In pediatric patients, several studies have demonstrated the benefit of high flow measured as pressure rate product (PRP). PRP is a product of delta pleural pressure (∆Pes) multiplied by respiratory rate. In a study by Rubin et al. on children age <18-year-old, the average body weight of 6.4 kg in pediatric intensive care room recorded pleural pressure and respiratory rate using HFNC at flows of 2, 5, 8 L/min. The flow of 8 L/min demonstrated significantly lower PRP, ∆Pes, and respiratory rate compared to 2 L/min and 5 L/min.[12] Similarly, a study by Weiler et al. in subjects ≤ 3-year-old obtained improved PRP among patients with HFNC flow of 2 L/kg/min compared to 0.5L/kg/min and 1.5 L/kg/min.[13] Therefore, higher flow and higher velocity oxygen therapy generally confers a benefit.

Respiratory disorders pose a high risk of aspiration, hence the patient is usually incapable of oral feeding. Agitation due to oxygen therapy can delay nutritional feeding. A report from a previous study mentioned that oral feeding is well-tolerated in adults receiving a flow of 40 L/min.[1] Another study by Slain et al. on patients aged <1-year-old equipped with HFNC also reported that 90% were able to tolerate enteral nutrition within 24 hours, with similar incidences of emesis and respiratory distress between oral and enteral feeding methods.[14]

  Comparison Between High-Flow Nasal Cannula With Other Noninvasive Respiratory Support Top

Noninvasive respiratory supports for instance are high-flow nasal cannula, continuous positive airway pressure (CPAP), and noninvasive ventilator (Bi-level positive airway pressure (BiPAP)). There were several studies done to compare various noninvasive respiratory supports, most of them were done in bronchiolitis patients. Comfort was one of the issues regarding the use of noninvasive respiratory support, while the need for close monitoring during device installation is the other.

CPAP works by generating a certain degree of positive end-expiratory pressure (PEEP), distending airway pressure, and maintaining the patency of the airway. While BiPAP provides two levels of positive pressure, hence it can improve the functional residual capacity and decrease ventilation-perfusion (V-Q) mismatch. Both devices use a closed system, require special staff skills, close monitoring, and can be stressful to the child.[15],[16] In contrast, HFNC has been shown to have a better patient tolerance, less nose damage, and less work for the staff than CPAP and noninvasive ventilator.[17],[18] Vahlkvist et al. conducted an open randomized trial of HFNC and CPAP to explore the effects of treatment on respiratory variables in infants and young children with bronchiolitis. This study found similar effects on respiratory rate, Modified Woods Clinical Asthma Score (M-WCAS), and pCO2 compared to CPAP. Pain scores were significantly lower in the HFNC group indicating better patient acceptance. This study suggests that HFNC can be a good alternative to CPAP and an effective tool for respiratory support in young children with moderate-severe bronchiolitis.[19] Metge et al. also found no differences between HFNC and CPAP in terms of length of stay, respiratory rate, PaCO2, or FiO2 requirements.[15] Sarkar et al. found less nose damage with HFNC.[16]

A randomized control trial was also conducted by Chandra et al. in children aged 1–18 years who presented with or developed ARDS during their course of hospitalization.[17] This study compared oxygen therapy by HFNC and CPAP in pediatric ARDS patients (mean PaO2/FiO2 237.7). There was a higher incidence of hemodynamic instability, subsequent requirement of invasive ventilation, and longer total duration of respiratory support in the CPAP compared to the HFNC group. Hence this study concluded that HFNC has a higher efficacy in the management of PARDS. Subsequent requirement invasive ventilation and hemodynamic deterioration were significantly low with HFNC compared with CPAP.[17]

The installation of CPAP and NIV requires intensive care unit facility as it needs close monitoring, while HFNC can be used in the emergency department and even the patient ward. A previous study in bronchiolitis, pneumonia, and asthma patients in community pediatric wards showed a good result using HFNC installed in the emergency room and continued in the pediatric ward. The study described treatment failure with HFNC as defined by the presence of worsening breath requiring transfer to the ICU and only 18% of patients needed to be transferred to the intensive care unit with 6% of them needed intubation. Interestingly, this study found that younger age, prematurity, medical comorbidity, or a diagnosis of bronchiolitis, were not found to be risk factors for deterioration, in contrast to the hypothesis at the start of the study.[20] The findings of this study are in line with the study by Betters et al. which found that FiO2 requirement greater than 50% was the largest factor associated with HFNC failure outside of the ICU, despite a prior history of intubation and cardiac co-morbidity.[21]

  Limitations of the Use of High-Flow Nasal Cannula Top

Generally, HFNC is safe to use. Adverse events associated with its use are mild, such as epistaxis and skin irritation due to nasal cannula use and aerophagia. Serious adverse events like pneumothorax are very rare due to an open system of HFNC that prevent a sudden increase in airway pressure. An observational study by Baudin et al. on 177 patients in the pediatric intensive care unit showed 1% pneumothorax and 0.6% epistaxis incidence associated with HFNC use.[18] Although HFNC is relatively contraindicated in pneumothorax, a study on patients with pre-existing pneumothorax before heart surgery, showed no worsening of pneumothorax associated with HFNC use. Compared to CPAP, previous studies in neonates found similar pneumothorax incidence, with a higher rate of mucosal irritation associated with CPAP. However, in terms of noise created, HFNC creates more noise, reaching 80 dB and increasing according to its flow.[5]

The failure rate of HFNC in children varies from 6–20%.[5],[18],[21] In the emergency room, the HFNC failure rate in patients presenting with dyspnea that require intubation is 8–11%.[8],[21],[22] In 2013, Betters et al. conducted a retrospective study on 231 pediatric patients with a median age of 6.9 months and body weight of 7.3 kg. The majority (83%) presented with primary diagnoses of respiratory problems, that is, bronchiolitis (64%), pneumonia, asthma, and croup. This study reported a rate of HFNC failure of 6% and failure was associated with existing heart abnormalities (P < 0.001), history of intubation (P < 0.001), and FiO2 requirement of 60–100% (P < 0.001).[21] Kelly et al. reported an 8% failure rate of HFNC. In this report, failure was associated with risk factors such as respiratory rate (>p90 (OR 2.11)), pCO2 level (>50 mmHg (OR 2.5)), and venous pH (7.30 (OR 2.53)) on arrival.[23] Similarly, an observational study by Long et al. on children with persistent respiratory distress and hypoxemia obtained HFNC failure of 11% in which patients eventually required intubation.[8]

  Summary Top

This review briefly summarizes the use of high-flow nasal cannula as a noninvasive oxygen therapy in pediatric patients. High-flow nasal cannula delivers high flow and high velocity of oxygen that may confer respiratory benefit in many clinical conditions. Its use is generally safe and thus can potentially be widely used for pediatric patients who need respiratory assistance.


NWP contributed to the concept, literature searching and writing of the manuscript, Rismala Dewi, M.D., Ph.D. contributed to the development of this article, as well as critical revision of this manuscript. We would like to express our gratitude to Antonius H. Pudjiadi, M.D., Ph.D. who provided her clinical expertise in the writing of this manuscript, Ashfahani Imanadhia, M.D, for language assistance.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Slain KN, Shein SL, Rotta AT The use of high-flow nasal cannula in the pediatric emergency department. J Pediatr (Rio J) 2017;93 Suppl 1:36-45.  Back to cited text no. 1
Mikalsen IB, Davis P, Øymar K High flow nasal cannula in children: A literature review. Scand J Trauma Resusc Emerg Med 2016;24:1. doi:10.1186/13049-016-0278-4. https://sjtrem.biomedcentral.com/articles/10.1186/s13049-016-0278-4  Back to cited text no. 2
Roston E Oxygen therapy. In: Marino PL, editor. The ICU Book. 4th ed. Philadelphia: Wolter Kluwer Lippincott Health/William&Walkins; 2014. pp. 427-46.  Back to cited text no. 3
Abboud P, Raake JWD Supplemental oxygen and bag valve mask ventilation. In: Wheeler DS, Wong HR, Shanley TP, editors. Pediatric Critical Care Medicine: Basic Science and Clinical Evidence. London: Springer; 2007. pp. 217-22.  Back to cited text no. 4
Milési C, Boubal M, Jacquot A, Baleine J, Durand S, Odena MP, et al. High-flow nasal cannula: Recommendations for daily practice in pediatrics. Ann Intensive Care 2014;4:29.  Back to cited text no. 5
Ramnarayan P, Schibler A Glass half empty or half full? The story of high-flow nasal cannula therapy in critically ill children. Intensive Care Med 2017;43:246-9. doi: 10.1007/s00134-016-4663-2. https://pubmed.ncbi.nlm.nih.gov/28124737/  Back to cited text no. 6
Mardegan V, Priante E, Lolli E, Lago P, Baraldi E Heated, humidified high-flow nasal cannulae as a form of noninvasive respiratory support for preterm infants and children with acute respiratory failure. Am J Perinatol 2016;33:1058-61.  Back to cited text no. 7
Long E, Babl FE, Duke T Is there a role for humidified heated high-flow nasal cannula therapy in paediatric emergency departments? Emerg Med J 2016;33:386-9.  Back to cited text no. 8
Spoletini G, Alotaibi M, Blasi F, Hill NS Heated humidified high-flow nasal oxygen in adults: Mechanisms of action and clinical implications. Chest 2015;148:253-61.  Back to cited text no. 9
Oto A, Erdoğan S, Boşnak M Oxygen therapy via high flow nasal cannula in pediatric intensive care unit. Turk J Pediatr 2016;58:377-82. doi:10.24953/turkjped.2016.04.005. https://pubmed.ncbi.nlm.nih.gov/28276209/  Back to cited text no. 10
Corley A, Caruana LR, Barnett AG, Tronstad O, Fraser JF Oxygen delivery through high-flow nasal cannulae increase end-expiratory lung volume and reduce respiratory rate in post-cardiac surgical patients. Br J Anaesth 2011;107:998-1004.  Back to cited text no. 11
Rubin S, Ghuman A, Deakers T, Khemani R, Ross P, Newth CJ Effort of breathing in children receiving high-flow nasal cannula. Pediatr Crit care Med a J Soc Crit Care Med World Fed Pediatr Intensive Crit Care Soc 2014;15:1-6. doi: 10.1097/PCC.0000000000000011. https://pubmed.ncbi.nlm.nih.gov/24201859/  Back to cited text no. 12
Weiler T, Kamerkar A, Hotz J, Ross PA, Newth CJL, Khemani RG The relationship between high flow nasal cannula flow rate and effort of breathing in children. J Pediatr 2017;189:66-71.e3.  Back to cited text no. 13
Slain KN, Martinez-Schlurmann N, Shein SL, Stormorken A Nutrition and high-flow nasal cannula respiratory support in children with bronchiolitis. Hosp Pediatr 2017;7:256-62.  Back to cited text no. 14
Metge P, Grimaldi C, Hassid S, Thomachot L, Loundou A, Martin C, et al. Comparison of a high-flow humidified nasal cannula to nasal continuous positive airway pressure in children with acute bronchiolitis: Experience in a pediatric intensive care unit. Eur J Pediatr 2014;173:953-8.  Back to cited text no. 15
Sarkar M, Sinha R, Roychowdhoury S, Mukhopadhyay S, Ghosh P, Dutta K, et al. Comparative study between noninvasive continuous positive airway pressure and hot humidified high-flow nasal cannulae as a mode of respiratory support in infants with acute bronchiolitis in pediatric intensive care unit of a tertiary care hospital. Indian J Crit Care Med 2018;22:85-90.  Back to cited text no. 16
[PUBMED]  [Full text]  
Chandra DS, Vijayshri DV, Gupta DA, Goyal DP, Prasad DPL High flow nasal cannula vs non-invasive ventilation in pediatric ARDS: An RCT. Pediatr Rev Int J Pediatr Res 2018;5:592-5. doi:10.17511/ijpr.2018.i11.07. https://pediatrics.medresearch.in/index.php/  Back to cited text no. 17
Baudin F, Gagnon S, Crulli B, Proulx F, Jouvet P, Emeriaud G Modalities and complications associated with the use of high-flow nasal cannula: Experience in a pediatric Icu. Respir Care 2016;61:1305-10.  Back to cited text no. 18
Feldman JD, Zusman A, Chaudry TE, Lyon L, Postlethwaite D Safety and efficacy of high flow nasal cannula use on pediatric wards. Pediatrics 2019;144:402.  Back to cited text no. 19
De Santis D, Sheriff F, Bester D, Kin RRT, Mph RS, Frcpc CH Uses of high-flow nasal cannula on the community paediatric ward and risk factors for deterioration. Paediatr Child Health 2020;25:102-6.  Back to cited text no. 20
Betters KA, Gillespie SE, Miller J, Kotzbauer D, Hebbar KB High flow nasal cannula use outside of the Icu; factors associated with failure. Pediatr Pulmonol 2017;52:806-12.  Back to cited text no. 21
Spentzas T, Minarik M, Patters AB, Vinson B, Stidham G Children with respiratory distress treated with high-flow nasal cannula. J Intensive Care Med 2009;24:323-8.  Back to cited text no. 22
Kelly GS, Simon HK, Sturm JJ High-flow nasal cannula use in children with respiratory distress in the emergency department: Predicting the need for subsequent intubation. Pediatr Emerg Care 2013;29:888-92.  Back to cited text no. 23


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