High-flow versus standard nasal cannula oxygenation during prone-position ERCP under nurse-administered propofol sedation: a randomized controlled trial

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Abstract
Background Hypoxemia affects up to 23% of patients undergoing ERCP under nurse-administered propofol sedation (NAPS) with a standard nasal cannula (SNC). High-flow nasal cannula (HFNC) provides heated, humidified oxygen at high gas flow with more controlled inspired oxygen delivery than conventional low-flow oxygen and may reduce hypoxemic events during sedation. We compared HFNC with SNC during ERCP under NAPS. Methods In this two-center, prospective, randomized trial, 300 adults undergoing ERCP between October 2025 and June 2026 were allocated 1:1 to HFNC (flow 50 L/min; FiO2 0.50) or SNC (5 L/min). All procedures were performed in the prone position under propofol-based NAPS. The primary outcome was hypoxemia (SpO2 < 92% for > 10 s). Secondary outcomes included airway interventions and cardiovascular events. Results Baseline characteristics, procedural factors, and sedation dosages were comparable. Hypoxemia occurred in 2 of 150 patients (1.3%) with HFNC versus 21 of 150 (14.0%) with SNC (RR 0.10, 95% CI 0.02–0.36; P < 0.001). Jaw-thrust maneuvers (1.3 vs. 12.0%; P < 0.001) and nasopharyngeal airway insertion (0 vs. 9.3%; P < 0.001) were also less frequent with HFNC. No patient required emergency intubation. Hypotension was more frequent with HFNC (16.7 vs. 8.0%; P = 0.02), but no episode required vasopressors or procedure termination. In post hoc analyses, HFNC reduced hypoxemic events in both BMI subgroups; however, the treatment-by-BMI interaction was not significant (P for interaction = 0.65). Conclusions HFNC oxygenation strategy reduced hypoxemic events and rescue airway interventions during ERCP under NAPS, although transient hypotension occurred more frequently. No significant treatment-by-BMI interaction was observed. Trial registry Thai Clinical Trials Registry, TCTR20250901001. Graphical abstract

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