Efficacy and Safety of High-Flow Nasal Cannula Versus Continuous Positive Airway Pressure and Conventional Oxygen Therapies in Pediatric Acute Respiratory Failure: A Systematic Review and Meta-Analysis Publisher Pubmed



Memar E H E ; Shirzadi R ; Rahsepar N S ; Ashtari S
Source: BMC Pediatrics Published:2026

Abstract

Background: Pediatric acute respiratory failure (ARF) is a significant clinical challenge, often requiring respiratory support. While Continuous Positive Airway Pressure (CPAP) and conventional oxygen therapy (COT) are standard treatments, High-Flow Nasal Cannula (HFNC) has emerged as a promising non-invasive alternative, though its benefits remain unclear. This study aimed to compare the efficacy and safety of HFNC versus CPAP and COT in treating pediatric ARF. Methods: A literature search was conducted in Embase, PubMed, Cochrane Library, Scopus, and Web of Science until June 15, 2026. Randomized controlled trials (RCTs) comparing HFNC with CPAP and COT in children with ARF secondary to acute severe asthma, bronchiolitis, or pneumonia were included. Primary outcomes were treatment failure and intubation rates; secondary outcomes included oxygen therapy duration, pediatric intensive care unit (PICU) length of stay (LOS), hospital LOS, and mortality. Quality assessment used the Cochrane Risk of Bias Tool, and a random-effects meta-analysis was performed to calculate pooled odds ratios (ORs) and mean differences (MDs). Results: A total of 22 RCTs involving 6,641 children were included in this analysis. Compared to COT, HFNC was associated with a significantly lower risk of treatment failure (OR: 0.509, 95% CI: 0.42–0.61). However, there were no significant differences in intubation rates (OR: 0.796, 95% CI: 0.39–1.63) or hospital mortality (OR: 0.654, 95% CI: 0.4–1.06) between the HFNC and COT groups. Compared to CPAP, HFNC showed increased risks for treatment failure (OR: 1.343, 95% CI: 0.75–2.4), intubation rates (OR: 1.044, 95% CI: 0.58–1.89), and hospital mortality (OR: 3.11, 95% CI: 0.96–10.1), although these increases did not reach statistical significance (P > 0.05). Additionally, there were no significant differences in the duration of oxygen therapy, pediatric PICU LOS, or hospital LOS between HFNC and either CPAP or COT. Conclusions: HFNC significantly reduces the risk of treatment failure compared to conventional oxygen therapy in children with ARF, though it does not differ significantly from CPAP regarding intubation rates or hospital mortality. Further research is necessary to clarify its relative efficacy and safety in comparison to CPAP. Clinical trial registration: CRD420250652913 © The Author(s) 2026.