Randomised controlled trial of oxygen therapy and high-flow nasal therapy in African children with pneumonia

Document Type



Paediatrics and Child Health (East Africa)


Purpose: The life-saving role of oxygen therapy in African children with severe pneumonia is not yet established.

Methods: The open-label fractional-factorial COAST trial randomised eligible Ugandan and Kenyan children aged>28 days with severe pneumonia and severe hypoxaemia stratum (SpO2<80%) to high-flow nasal therapy (HFNT) or low-fow oxygen (LFO: standard care) and hypoxaemia stratum (SpO2 80–91%) to HFNT or LFO (liberal strategies) or permissive hypoxaemia (ratio 1:1:2). Children with cyanotic heart disease, chronic lung disease or>3 h receipt of oxygen were excluded. The primary endpoint was 48 h mortality; secondary endpoints included mortality or neurocognitive sequelae at 28 days.

Results: The trial was stopped early after enrolling 1852/4200 children, including 388 in the severe hypoxaemia stratum (median 7 months; median SpO2 75%) randomised to HFNT (n=194) or LFO (n=194) and 1454 in the hypoxaemia stratum (median 9 months; median SpO2 88%) randomised to HFNT (n=363) vs LFO (n=364) vs per‑ missive hypoxaemia (n=727). Per-protocol 15% of patients in the permissive hypoxaemia group received oxygen (when SpO2<80%). In the severe hypoxaemia stratum, 48-h mortality was 9.3% for HFNT vs. 13.4% for LFO groups. In the hypoxaemia stratum, 48-h mortality was 1.1% for HFNT vs. 2.5% LFO and 1.4% for permissive hypoxaemia. In the hypoxaemia stratum, adjusted odds ratio for 48-h mortality in liberal vs permissive comparison was 1.16 (0.49–2.74; p=0.73); HFNT vs LFO comparison was 0.60 (0.33–1.06; p=0.08). Strata-specific 28 day mortality rates were, respectively: 18.6, 23.4 and 3.3, 4.1, 3.9%. Neurocognitive sequelae were rare.

Conclusions: Respiratory support with HFNT showing potential beneft should prompt further trials


This work was published before the author joined Aga Khan University.

Publication (Name of Journal)

Springer Berlin Heidelberg

Creative Commons License

Creative Commons Attribution 4.0 International License
This work is licensed under a Creative Commons Attribution 4.0 International License.