First10EM on theSGEM!

I was honoured to be invited on The Skeptics Guide to Emergency Medicine this week to discuss the FLORALI trial with Ken Milne.

The episode is: SGEM#135: The Answer My Friend is Blowin’ in your Nose – High Flow Nasal Oxygen


I had previously mentioned this paper in the May 2015 edition of my Articles of the Month.

My Bottom line: High flow nasal oxygen seems to be as good as NIPPV or facemask oxygen (in this select group of patients). This is enough for me to try this with alert pneumonia patients who don’t obviously need intubation.

I personally like high flow nasal oxygen for a lot of these patients, because it seems to be more comfortable, allow for easier communication, and provides the option of oral intake. This study certainly is not enough to justify the expense of purchasing one of these units if you don’t already have one. However, if there is already one in your department, I say give it a trial.

Two major questions remain, in my mind:

  1. In these hypoxic patients, when should we be intubating? Does placing a patient on high flow nasal oxygen simply delay the inevitable intubation? Might that lead to worse outcomes?
  2. Was this study underpowered to show a benefit? They powered the study to show a 20% decrease in intubation and the study was negative. However, the point estimates were better for high flow nasal oxygen in all categories. Also, a secondary outcome of mortality at 90 days was statistically better in the high flow group. We need more trials to determine the real effect of high flow nasal oxygen.

For a proper skeptical take on this paper, go listen to the episode!



Frat JP, Thille AW, Mercat A, et al. High-Flow Oxygen through Nasal Cannula in Acute Hypoxemic Respiratory Failure. N Engl J Med. 2015. PMID: 25981908

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