Prophylactic high-flow nasal oxygen vs. conventional oxygen for prevention of postoperative respiratory complications: a randomized trial

Postoperative pulmonary complications (PPCs) are a major cause of morbidity after lung resection, particularly in older adults. Following extubation, noninvasive respiratory support strategies are increasingly used to prevent respiratory deterioration, but the role of prophylactic high-flow nasal cannula (HFNC) in this setting remains uncertain. In this single-center, open-label randomized controlled trial, patients undergoing video-assisted thoracoscopic surgery (VATS) lobectomy or segmentectomy for stage I–IIIa non-small cell lung cancer (NSCLC) were randomized to HFNC or conventional oxygen therapy (COT). The primary outcome was PPC severity during hospitalization, analyzed using ordinal logistic regression; the incidence of clinically relevant PPCs (grade ≥ 2) was also compared between groups. Secondary outcomes included longitudinal respiratory symptoms (mMRC, LCQ-MC, sCSS) and symptom-related functional interference (MDASI-LC), analyzed using mixed-effects models. A total of 210 patients were included in the modified intention-to-treat analysis (HFNC, n = 104; COT, n = 106). HFNC reduced PPC severity (ordinal OR, 0.50; 95% CI, 0.28–0.91; P = 0.022) and moderate-to-severe PPCs (23.1% vs. 39.6%; absolute risk difference, -15.6%; 95% CI, -28.0% to -3.2%; P = 0.010). HFNC was associated with a lower burden of clinically relevant PPCs. Secondary analyses also suggested improvements in early postoperative respiratory symptoms and symptom-related functional interference. Secondary analyses also suggested improvements in early postoperative respiratory symptoms and symptom-related functional interference. No differences were observed in physiological outcomes or length of stay. In older adults undergoing lung resection, prophylactic HFNC reduced in-hospital PPC burden and was associated with more favorable early postoperative respiratory recovery. These findings suggest that prophylactic HFNC may provide benefit as a potential preventive respiratory support option in selected older or higher-risk postoperative patients, although routine prophylactic use in all patients undergoing lung resection is not supported by the present findings. This study was approved by the Chinese Clinical Trial Registry (ChiCTR2200063161) on 01 Sep 2022 and the first patient was enrolled after pre-registration.