Effect of high-flow nasal oxygen therapy on perioperative hypoxemia in children: a systematic review and meta-analysis.

BACKGROUND

Hypoxia is the leading cause of complications and death during anesthesia. The risk of hypoxemia in children is higher than in adults. The use of high-flow nasal cannula (HFNC) can prevent desaturation of blood oxygen saturation in children. This meta-analysis aimed to compare the effectiveness of HFNC and conventional oxygenation methods in reducing perioperative desaturation in pediatric patients.

METHODS

The standard database was searched from the beginning till April 2024. Studies including perioperative use of HFNC had at least one of the following five outcomes: (1) incidence of desaturation, (2) minimum O saturation, (3) safe apnea time, (4) terminal transcutaneous Carbon dioxide (TcCO), and (5) additional interventions. The perioperative period is divided into three stages: general anesthesia induction, intraoperative sedation, and postoperative extubation.

RESULTS

This meta-analysis included eight randomized controlled trials (one induction, five surgeries, two extubations; 653 patients total). Compared to conventional oxygen therapy, HFNC had a perioperative desaturation relative risk of 0.42 (95% CI: 0.18, 0.98;  = ) and improved minimum oxygen saturation with a mean difference of 5.58 (95% CI: 1.27, 9.89;  = ). Notably, the HFNC group had a relative risk of 0.44 (95% CI: 0.27, 0.69;  = ) for requiring special interventions. However, no significant differences were observed between groups in safe apnea time (mean difference 0.78, 95% CI: -4.73, 6.29;  = ) or final transcutaneous carbon dioxide (TcCO) levels (mean difference -0.74, 95% CI: -2.88, 1.40;  = ).

CONCLUSIONS

Compared with conventional oxygenation, HFNC use is associated with a lower risk of desaturation, higher minimum O saturation, and reduced need for additional interventions, while maintaining comparable safe apnea time and CO levels during perioperative application. These findings suggest that HFNC may be a valuable tool for pediatric patients with anticipated difficult intubation, apnea-prone airway surgery, or postoperative extubation challenges. However, the results should be interpreted with caution due to limitations, including the small number of included studies, heterogeneity in clinical settings (e.g., anesthesia phases and surgical types), and potential variability in outcome definitions. Further large-scale trials are needed to confirm these findings, particularly in high-risk subgroups and various perioperative contexts.

REGISTRATION NUMBER

CRD42024545348.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1186/s12871-025-03214-8.