# High-Flow Nasal Cannula for Peri-Intubation Oxygenation in Pediatric Rapid Sequence Intubation: A Narrative Best-Evidence Review

## TL;DR

This paper reviews evidence on using high-flow nasal cannula during pediatric intubation to improve oxygenation and reduce hypoxemia risks.

## Contribution

The paper provides a narrative best-evidence review on HFNC use in pediatric RSI, highlighting gaps in current evidence and suggesting future trial directions.

## Key findings

- HFNC improves oxygenation reliability and reduces desaturation events in pediatric patients.
- Benefits of HFNC vary depending on baseline hypoxemia and comparator strategies.
- More pediatric-specific RSI trials with standardized protocols are needed for conclusive evidence.

## Abstract

Pediatric rapid sequence intubation (RSI) carries a high risk of peri-intubation hypoxemia because children have limited oxygen reserve and desaturate rapidly during apnea. High flow nasal cannula (HFNC) is an appealing adjunct because it can deliver high, humidified flows that reduce room air entrainment and support a more stable upper airway oxygen concentration, with modest flow and leak-dependent distending pressure and upper airway dead space washout. Across pediatric perioperative and sedation studies and in acute care cohorts, the most consistent signal is improved oxygenation reliability, with fewer or less severe desaturation events and fewer rescue interventions, rather than a predictable extension of safe apnea time, which remains variable across settings. Adult peri-intubation trials provide a comparator context and reinforce that the observed benefit depends on baseline hypoxemia and the comparator strategy, often favoring NIV in severe hypoxemia, limiting direct generalization to children. Pediatric RSI-specific randomized trials are needed with standardized flow protocols and clinically meaningful endpoints, including severe desaturation rates, nadir SpO₂, time spent below clinically relevant thresholds, need for rescue ventilation or interrupted laryngoscopy, first pass success, and adverse events.