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Multicenter randomized trial finds flow-first, oxygen-first, and simultaneous HFNC weaning yield equivalent success rates in critically ill adults

Critical care medicine (PubMed)Oct 15, 2026

AI-summarized from the linked source. Educational brief, not medical advice.

Brief summary

A multicenter randomized controlled trial of 87 critically ill adults found no significant differences in 24-hour weaning success (94% vs 81% vs 77%) or duration between flow-reduction-first, FiO2-reduction-first, or simultaneous HFNC weaning.

What NurseJet pulled from the source

High-flow nasal cannula (HFNC) is standard supportive therapy for acute hypoxemic respiratory failure, yet clinical teams lack consensus on the optimal stepwise de-escalation sequence. The multicenter, randomized controlled SLOWH trial enrolled 102 adults across three tertiary care intensive care units who achieved clinical stability on HFNC and met standardized weaning criteria (PaO2/FiO2 >= 150 or SpO2 >= 92% on FiO2 <= 0.40 and flow <= 30 L/min). Following exclusions, 87 patients were randomized to flow reduction first (FR, n=31), FiO2 reduction first (OR, n=26), or simultaneous reduction (SR, n=30). The primary outcome was successful transition to conventional oxygen therapy without HFNC resumption, noninvasive ventilation, or endotracheal intubation within 24 hours. Weaning success was achieved in 94% of the FR group, 81% of the OR group, and 77% of the SR group (p = 0.15). Median weaning duration was also comparable: 31.0 hours for FR, 29.5 hours for OR, and 29.5 hours for SR (p = 0.87).

Why this matters for nurses

ICU and step-down nurses frequently manage HFNC titration and weaning trials at the bedside. Evidence demonstrating clinical equivalence across sequential flow reduction, FiO2 reduction, and simultaneous titration allows nurses and respiratory therapists to tailor the weaning trajectory to individual patient physiology—such as prioritizing flow reduction for airway comfort or FiO2 reduction to limit oxygen toxicity.

Bedside takeaway

In an 87-patient multicenter RCT of critically ill adults, flow-first (94%), FiO2-first (81%), and simultaneous (77%) HFNC weaning showed comparable 24-hour success rates (p=0.15) and similar median weaning durations (~30 hours).

Key takeaways

Multicenter RCT of 87 adults across 3 tertiary ICUs compared flow-first (n=31), oxygen-first (n=26), and simultaneous (n=30) HFNC de-escalation.
Weaning success rates at 24 hours did not significantly differ between strategies: 94% flow-first, 81% oxygen-first, and 77% simultaneous (p = 0.15).
Median weaning duration was approximately 30 hours across all three arms (31.0 hr vs 29.5 hr vs 29.5 hr, p = 0.87).
Findings indicate bedside clinicians can individualize HFNC weaning order based on patient comfort and work of breathing without compromising weaning success.

Practice implications

Assess work of breathing, accessory muscle use, and oxygenation saturation during HFNC de-escalation; whether titrating flow or FiO2 first, titrate gradually per provider orders and monitor closely for respiratory fatigue within the initial 24 hours of step-down.

Limitations & cautions

Relatively modest sample size (87 completed participants) may have been underpowered to detect small differences between weaning arms; conducted in tertiary academic centers with dedicated protocols.
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Critical care medicine (PubMed)

Critical care medicine (PubMed). Weaning Strategies for High-Flow Nasal Cannula in Critically Ill Adults: A Randomized Clinical Trial.

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https://pubmed.ncbi.nlm.nih.gov/42878628/

Professional education only

This summary does not replace clinical judgment, facility policy, provider orders, or official guidelines. Verify practice changes against the original source and local protocol.

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Pediatrics (PubMed)Oct 20, 2026Research Article

A randomized crossover simulation trial of 123 emergency clinicians found that real-time device feedback dramatically improved pediatric bag-valve-mask ventilation quality, increasing guideline-adherent tidal volumes from 16.2% to 87.0%.

Peds EmergencyAI summaryReview source

Research ArticleResearchQuality ImprovementPatient EducationAI summary · original source linked below

Manual bag-mask ventilation is a critical, lifesaving intervention for children suffering acute respiratory arrest, but delivery of appropriate pediatric tidal volumes without barotrauma or gastric insufflation remains challenging. In a single-anonymized, randomized crossover trial across five emergency medical services agencies in three US metropolitan areas, 123 emergency clinicians ventilated a high-fidelity manikin simulating a 3-year-old child in respiratory arrest. Participants completed two sequential 2-minute ventilation trials—one with real-time visual feedback using the EOLifeX ventilation feedback device (VFD) and one without feedback—separated by a 10-minute washout period. Real-time feedback increased adherence to age-recommended tidal volumes from 16.2% to 87.0%. Ventilation rate adherence improved from 65.0% to 88.6%, and minimal mask leak (<30%) was maintained in 88.4% of breaths with feedback compared to 80.0% without feedback.

Key takeaways

Randomized crossover simulation study evaluated 123 emergency clinicians ventilating a simulated 3-year-old toddler.
Unassisted baseline ventilation rarely met pediatric standards, with only 16.2% of breaths delivering guideline-recommended tidal volumes.
Real-time visual feedback increased guideline-compliant tidal volume delivery to 87.0% and rate adherence from 65.0% to 88.6%.
Mask seal with less than 30% leak improved from 80.0% to 88.4% when feedback was active.

Why this matters on shift

Pediatric emergency nurses and rapid response teams frequently provide manual ventilation during arrests and severe respiratory compromise. Because children have high chest wall compliance and low functional residual capacity, unguided manual bagging frequently leads to severe hyperventilation or dangerous overdistention. Objective feedback devices provide immediate visual cues that safeguard against excessive tidal volumes and erratic rates.

Bedside takeaway

In a randomized crossover study of 123 emergency clinicians ventilating a 3-year-old child manikin, real-time feedback increased guideline-adherent tidal volume delivery from 16.2% to 87.0% and rate adherence from 65.0% to 88.6%.

Nursing implications

When delivering bag-mask ventilation to pediatric patients, use two-person technique when possible to optimize mask seal, utilize volume-limiting and feedback-guided adjuncts per unit protocol, and maintain deliberate, age-appropriate ventilation rates.

Limitations & cautions

Simulation manikin model evaluating simulated respiratory arrest rather than live clinical patient outcomes; short 2-minute testing intervals may not reflect clinician physical fatigue during prolonged resuscitations.
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Citations · exact source links

Pediatrics (PubMed). Prehospital Pediatric Ventilation Quality Following Use of a Feedback Device: A Randomized Study.

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Obstetrics and gynecology (PubMed)Oct 20, 2026Systematic Review

A systematic review and meta-analysis of 15 randomized controlled trials encompassing 1,874 pregnant individuals found mifepristone for labor induction at term was associated with a 33% reduction in the odds of cesarean delivery compared to control methods.

L&D / OB Med-SurgAI summaryReview source

Systematic ReviewResearchMedication SafetyQuality ImprovementAI summary · original source linked below

Cervical ripening is often the longest and most unpredictable phase of labor induction, prompting investigation of oral progesterone receptor antagonists. Investigators conducted a systematic review and meta-analysis conforming to PRISMA guidelines and registered in PROSPERO (CRD420251236886), searching MEDLINE, Embase, Scopus, and ClinicalTrials.gov through October 2025. Across 15 eligible randomized controlled trials evaluating mifepristone for labor induction in singleton pregnancies at 37 weeks or greater (1,063 receiving mifepristone and 811 control participants), mifepristone was associated with significantly reduced odds of cesarean delivery (33.1% vs 41.9%; odds ratio [OR] 0.67; 95% CI, 0.54-0.82). Sensitivity analyses restricted to placebo-controlled, high-quality trials demonstrated a consistent protective effect (OR 0.58; 95% CI, 0.40-0.83). Mifepristone also improved 24-hour Bishop scores, shortened induction-to-delivery time, and decreased requirements for supplemental oxytocin and prostaglandins, without observed increases in postpartum hemorrhage or NICU admissions.

Key takeaways

Systematic review and meta-analysis synthesized 15 randomized controlled trials comprising 1,874 term singleton pregnancies.
Mifepristone was associated with a 33% reduction in the odds of cesarean delivery compared with control induction methods (33.1% vs 41.9%, OR 0.67, 95% CI 0.54-0.82).
In high-quality placebo-controlled trials, the odds of cesarean delivery remained significantly lower (OR 0.58, 95% CI 0.40-0.83).
Treated patients demonstrated higher 24-hour Bishop scores, shorter induction-to-delivery intervals, and lower oxytocin utilization.

Why this matters on shift

Labor and delivery nurses are essential in monitoring cervical ripening, administering induction pharmacotherapy, and managing prolonged labor. Understanding the physiologic mechanisms and clinical outcomes of progesterone receptor blockade helps perinatal nurses anticipate cervical changes, titrate subsequent oxytocin infusions safely, and support shared decision-making during term inductions.

Bedside takeaway

In a meta-analysis of 15 RCTs (1,874 women), mifepristone for labor induction at >=37 weeks was associated with a 33% reduction in cesarean delivery odds (33.1% vs 41.9%, OR 0.67), higher 24-hour Bishop scores, and lower oxytocin use.

Nursing implications

Review physician orders and institutional induction protocols when administering ripening agents, perform serial Bishop scoring, maintain continuous fetal heart rate monitoring during active labor, and monitor for uterine tachysystole when combining ripening agents with oxytocin.

Limitations & cautions

Variable mifepristone dosing regimens across trials; secondary safety endpoints such as postpartum hemorrhage and NICU admission were inconsistently reported across primary studies.
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Citations · exact source links

Obstetrics and gynecology (PubMed). Progesterone Receptor Antagonists for Labor Induction: A Systematic Review and Meta-analysis.

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Resuscitation (PubMed)Sep 25, 2026Research Article

A Bayesian secondary analysis of the 6,082-patient PARAMEDIC-3 trial calculated an 81.6% posterior probability that an intraosseous-first access strategy was inferior to intravenous-first access for 30-day survival in out-of-hospital cardiac arrest.

Emergency TelemetryAI summaryReview source

Research ArticleResearchMedication SafetyQuality ImprovementAI summary · original source linked below

Securing rapid vascular access for resuscitation drug delivery is critical in cardiac arrest, but the relative clinical efficacy of intraosseous (IO) versus intravenous (IV) cannulation remains debated. Investigators conducted a pre-planned Bayesian secondary analysis of the multicenter PARAMEDIC-3 randomized trial (ISRCTN14223494), in which 6,082 adults experiencing non-traumatic out-of-hospital cardiac arrest were randomized to an initial IO-first or IV-first vascular access strategy. Using non-informative priors adjusted for baseline covariates, the posterior probability that IO-first access improved 30-day survival (odds ratio [OR] > 1.0) was only 18.4%, corresponding to an 81.6% probability that IO-first access was inferior (OR < 1.0). The probability of a small disadvantage (OR < 0.9) was 55.0%, and moderate disadvantage (OR < 0.75) was 13.4%. Similar patterns emerged for favorable neurological outcome, while for return of spontaneous circulation (ROSC) at hospital handover, the probability of IO inferiority was 98.0%.

Key takeaways

Pre-planned Bayesian secondary analysis of the PARAMEDIC-3 trial evaluated 6,082 adult out-of-hospital cardiac arrest patients.
Posterior probability that an IO-first approach improved 30-day survival was only 18.4%, with an 81.6% probability of inferiority compared with IV-first.
The probability that IO-first was inferior for return of spontaneous circulation (ROSC) at hospital handover was 98.0%.
Findings indicate that while intraosseous access is vital when IV access cannot be obtained, initial intravenous access remains clinically preferred for drug efficacy.

Why this matters on shift

Emergency and trauma nurses frequently manage vascular access during cardiac arrests in the emergency department and resuscitation bays. While IO devices provide rapid and reliable placement during difficult access, these Bayesian findings reinforce that intravenous administration delivers superior pharmacokinetics and resuscitation outcomes, supporting intravenous attempts as primary whenever readily achievable.

Bedside takeaway

In a Bayesian analysis of the 6,082-patient PARAMEDIC-3 trial, initial intraosseous access had an 81.6% posterior probability of inferior 30-day survival and 98.0% probability of inferior ROSC compared with initial intravenous access in cardiac arrest.

Nursing implications

Prioritize rapid intravenous cannulation attempts for resuscitation pharmacotherapy during cardiac arrest per ACLS protocols; deploy intraosseous access without delay when peripheral IV attempts fail or are clinically unfeasible.

Limitations & cautions

Secondary analysis of trial data subject to protocolized prehospital paramedic workflows; primary analysis modeled non-informative priors; exact drug delivery transit times were not directly measured.
AI-summarized from the linked source. Review the original article before applying to practice.

Citations · exact source links

Resuscitation (PubMed). Intraosseous versus intravenous access in adult out-of-hospital cardiac arrest: a Bayesian secondary analysis of the PARAMEDIC-3 randomised controlled trial.

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AI-summarized from the linked source. Review the original article before applying to practice.

Key takeaways

Practice implications

Limitations & cautions

Exact source links

More updates for this clinical area

Randomized simulation trial of 123 emergency clinicians finds real-time feedback increases pediatric bag-mask ventilation volume compliance from 16% to 87%

Meta-analysis of 15 randomized trials associates mifepristone labor induction with 33% lower odds of cesarean delivery in term singleton pregnancies

Bayesian analysis of 6,082-patient PARAMEDIC-3 trial calculates 82% posterior probability of inferior survival with initial intraosseous vs intravenous access in cardiac arrest