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Adjustment of high flow nasal cannula rates using real-time work of breathing indices in premature infants with respiratory insufficiency



To assess the feasibility of real-time monitoring of work of breathing (WOB) indices and the impact of adjusting HFNC flow on breathing synchrony and oxygen stability in premature infants.

Study design

A prospective, observational study of infants stable on HFNC. The flow adjusted per predetermined algorithm. Respiratory inductive plethysmography (RIP) noninvasively measured WOB. A high-resolution pulse oximeter collected oxygen saturation and heart rate data. Summary statistics and mixed linear models were used.


Baseline data for 32 infants, final analysis of 21 infants. Eighty-one percent with abnormal WOB. Sixty-two percent demonstrated 20% improvement in WOB. For infants with gestational age <28 weeks, an incremental increase in HFNC flow rate decreased WOB (p < 0.001) and improved oxygen saturation and stability (p < 0.01).


Premature infants do not receive optimal support on HFNC. The use of a real-time feedback system to adjust HFNC is feasible and improves WOB, oxygen saturation, and oxygen stability. This technology may improve the utility of HFNC in premature infants.

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Fig. 1: Pre-determined algorithm for adjustment of HFNC based on average phase angle and gestational age.
Fig. 2: Consort diagram describing eligibility, consent, and enrollment.
Fig. 3: Variability in oxygen saturation measured in terms of standard deviation at different HFNC flow (L/min) levels (p < 0.00, n = 21 infants).

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THS receives funding from NIH COBRE grant P30GM114736. KS is supported by an Institutional Development Aware (IDeA) from the National Institute of General Medical Sciences of the NIH grant U54-GM104941 (PI Binder-Macleod).

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Authors and Affiliations



KZK provided a substantial contribution to the conception, design, acquisition of data, analysis, and interpretation of the data. She was primarily responsible for the drafting of the article and has approved the submitted manuscript. RGL provided a substantial contribution to the conception, design, analysis, and interpretation of the data. He contributed significantly to the revision of the manuscript and has approved the submitted manuscript. ABM provided a substantial contribution to the design and acquisition of data. She contributed significantly to the revision of the manuscript and has approved the submitted manuscript. KS contributed significantly to the analysis and interpretation of the data and the drafting of the manuscript. He has approved the submitted manuscript. THS served as a mentor to the first author and provided a substantial contribution to the conception, design, and interpretation of the data. He played a significant role in the revision of the manuscript and has approved the submitted manuscript.

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Correspondence to Kelley Z. Kovatis.

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Kovatis, K.Z., Locke, R.G., Mackley, A.B. et al. Adjustment of high flow nasal cannula rates using real-time work of breathing indices in premature infants with respiratory insufficiency. J Perinatol 41, 1711–1717 (2021).

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