Written by Amanda Mathews
Spoon Feed
There was no difference in 28-day mortality for ICU patients with tachypnea and pulmonary infiltrates when comparing high-flow and standard flow oxygen, although intubations were lower in the high-flow group.
Not too high on high-flow oxygen
A prior RCT found high-flow nasal oxygen was noninferior to non-invasive ventilation. The new SOHO trial was conducted across 42 ICUs in France, enrolling 1116 patients randomized to standard oxygen or high-flow oxygen groups. Patients enrolled were admitted to the ICU with: RR >25, pulmonary infiltrates, and a PaO2:FiO2 ratio of ≤200 while breathing oxygen at a flow of ≥10 L/min by non-rebreather mask. Patients who were hypercarbic, had COPD or other chronic lung condition, had cardiogenic pulmonary edema, were altered, or required vasopressors were not included.
High-flow patients received at least 50L flow, and standard-flow patients received 10L of flow. Goal O2 saturations were between 92–96%. Primary outcome was 28-day all-cause mortality, with a secondary outcome of intubation within 28 days. The median duration of oxygen therapy for patients who did not undergo intubation was 4 days for both groups, and a small number of patients in both groups needed non-invasive ventilation as a rescue therapy (15 in high-flow group, 22 in standard group).
Mortality at day 28 was 14.6% in both groups. The incidence of intubation at day 28 was 42.4% (236/556 patients) in the high-flow group vs. 48.4% (268/554) in the standard-oxygen group (absolute difference –5.93; 95%CI –11.78 to –0.08). There was a non-statistically significant improvement in patient-perceived dyspnea in the high-flow group compared to the standard therapy.
How will this change my practice?
This is a very narrow use case and shows that empirically starting all hypoxic pneumonia patients on high-flow is not going to improve mortality outcomes (though I wonder how many physicians were doing this already). I will continue to carefully consider the patient and pathology in front of me when choosing how best to treat a patient with acute hypoxemic respiratory failure and focus on frequent reassessments with appropriate escalation/deescalation of support based on patient response.
Source
SOHO Trial Group and the REVA Network. High-Flow or Standard Oxygen in Acute Hypoxemic Respiratory Failure. N Engl J Med. 2026 Mar 17. doi: 10.1056/NEJMoa2516087. Epub ahead of print. PMID: 41841715.
