High Flow Therapy in the Newborn Infant

Publication: 22/11/2010  --
Last review: 30/08/2019  
Next review: 30/08/2022  
Clinical Protocol
ID: 2321 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2019  


This Clinical Protocol is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Protocol for the Use of High Flow Therapy in the Newborn Infant


High flow therapy (HFT) is a respiratory support  system in which warmed and humidified blended oxygen/air mixture is administered to a patient via nasal cannulae at flow rates >1 L/min1. It can be used to support the breathing of preterm and term infants.

The gas flow is delivered from a wall source that is directed into the machine where it is warmed and humidified. This enables the therapy to be better tolerated and the gas delivery to be at a greater rate than unheated or humidified gas (conventional low flow therapy). The heated and humidified gas travels to the patient via heated tubing. Only the last few centimetres are through conventional nasal cannulae. This minimises the loss of heat and humidity. The leak around the cannulae protects the infant against excessive end expiratory pressure (PEEP). As the flow rate increases so does the positive airways pressure. As the weight of the baby increases, the positive airway pressure at a given flow rate reduces. Thus, different sized cannulae are provided for different weight babies and gas flow is adjusted to produce a clinical improvement. However, it should be noted that the positive airway pressure is not measured and this is one of the concerns around its use.

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Advantages And Potential Disadvantages

Evidence to support or refute the use of HFT is increasing and it is a very useful addition to neonatal care. As such, patients should be carefully considered before HFT is administered.
The benefits of HFT are that it is a more comfortable interface for the baby and is less positional than CPAP, and as such may require less nursing time. Consequently, there is less likely to be nasal trauma. Access to the baby is easier and parents can interact more with their baby, e.g. skin to skin care is much easier.
The disadvantages of HFT are that the airway pressure is not measured, as it is with CPAP and as such theoretically increases the risk of air leaks (pneumothorax). There have been some reports of infection developing with the use of HFT and so guidance from the individual manufacturers of the devices must be followed.

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  • Primary respiratory support in term babies with signs of respiratory distress including  subcostal and intercostal recession, grunting and nasal flaring The presence of a condition thought to be responsive to CPAP and associated with one or more of the clinical presentations described above:
    • Post extubation following ventilation for respiratory distress syndrome
    • Atelectasis
    • Apnea of prematurity
  • Premature infants who are slow to wean off CPAP or infants with evolving chronic lung disease who need long term CPAP
  • Where there has been significant nasal trauma and CPAP is difficult or impossible

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  1. Primary support for respiratory distress in a preterm baby (Less than 37 weeks)
  2. The need for intubation and/or mechanical ventilation as evidenced by the presence of
    1. cardiovascular instability
    2. Unstable respiratory drive with frequent apnea
  3. Ventilatory failure as indicated by the inability to maintain acceptable blood gases
  4. Upper airways abnormalities that make it ineffective or potentially dangerous (e.g. choanal atresia, tracheo-esophageal fistula)
  5. Use with cleft palate with caution – only instigate with consultant involvement

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  • Start at 4 to 6 L/min.
  • Aim for oxygen saturations is as per protocol (91-94%).
  • Do not  use  a flow  greater than 6 L/min in infants weighing less than 1kg
  • Can use up to 8 L/min in infants greater than 1 kg, but if the baby is requiring FiO2 > 0.6, has increasing CO2 retention or apnoea s/he is likely to need alternative support.
  • Flow rate range 2 to 8 L/min (barotrauma, ‘CPAP belly’, nosocomial infection or nasal mucus plugging are thought not to occur at this flow rate 4,9,12)
  • A setting of 2 L/min or more should be counted as equivalent to CPAP for levels of care purposes.

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This is a guideline only and weaning should be adjusted to the individual patient.

  • If FiO2 <0.3 reduce flow rate by 0.5 L/min 12 hourly, more mature babies may tolerate weaning by 1l/min.
  • If FiO2 >0.3, flow rate should not be weaned unless clinically indicated.
  • When flow reaches 2L/min changing to  low flow oxygen therapy should be considered


Record: 2321

To facilitate the effective use of high flow therapy (HFT) in the newborn infant.


  • To understand the way high flow therapy works
  • To understand the advantages and disadvantages of  HFT
  • To understand the indications and contraindications for HFT.
  • To facilitate correct patient selection
Clinical condition:

Respiratory distress in the newborn

Target patient group: Neonates
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base


Manley BJ, Arnolda GRB et al for the HUNTER Trial Investigators. Nasal High-Flow Therapy for Newborn Infants in Special Care Nurseries. N Engl J Med 2019; 380:2031-2040

Roberts CT, Owen LS et al for the HIPSTER Trial InvestigatorsNasal High-Flow Therapy for Primary Respiratory Support in Preterm Infants. N Engl J Med 2016; 375:1142-1151

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

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