High-Flow Nasal Oxygen: An Effective Alternative in Anesthesia Induction

A randomized non-inferiority trial in adults undergoing frame-based stereoelectroencephalography (SEEG) found that high-flow nasal oxygen (HFNO) provides effective oxygenation during anesthesia induction and offers a practical alternative to facemask ventilation when headframes limit mask seal.

This single-center randomized trial compared preoxygenation and apneic oxygenation with high-flow nasal oxygen (HFNO) versus facemask preoxygenation with bag-mask ventilation. The primary endpoint was the lowest peripheral oxygen saturation (SpO2), assessed with blinded outcome adjudication and a prespecified non-inferiority margin of 2%. HFNO met the non-inferiority criterion: the median lowest SpO2 was 98% (IQR 97–99) with HFNO versus 96% (95–98) with facemask, with a median difference of 1% (95% CI 0–2%).

Secondary outcomes favored HFNO for procedural efficiency. Use of airway adjuncts was eliminated in the HFNO arm (0/23 HFNO vs 6/23 facemask; p=0.022), and time to secure the airway was shorter (median difference –16 seconds; p=0.015). These differences translated to fewer manual maneuvers and reduced need for oropharyngeal or nasopharyngeal adjuncts—an operational advantage when headframes limit facemask access.

Patient-centered outcomes and safety signals were reassuring: patient comfort scores improved (median difference 3 points; p<0.0001), no perioperative complications or excess desaturation events were reported in either group, and post-intubation PaO2 was higher with HFNO (median 437.8 mmHg vs 400.6 mmHg; p=0.002). Taken together, HFNO maintained oxygenation while improving clinician and patient acceptability in the studied cohort without detectable safety trade-offs.

Implementation requires staff familiarization with device setup, availability of appropriate HFNO systems and cannulae, and vigilance for CO2 accumulation during apneic periods. The evidence is limited by a single-center design and a modest sample (46 analyzed), which constrains generalizability to populations such as obese patients, children, or rapid-sequence intubation scenarios. HFNO is reasonable to adopt where equipment and training exist; broader implementation should await confirmatory studies across diverse anesthesia populations and settings.