Continuous Positive Airway Pressure vs High Flow Nasal Cannula for the Treatment of OSA in Children

Obstructive sleep apnea (OSA) is a common pediatric condition characterized by repeated episodes of upper airway obstruction during sleep. These episodes disrupt normal sleep patterns and oxygenation and are associated with significant short- and long-term health consequences. In children, untreated moderate-to-severe OSA has been linked to impaired quality of life, behavioral and emotional difficulties, impaired learning and school performance, cardiovascular and metabolic effects, and increased caregiver stress and health care utilization.

For many children, adenotonsillectomy is the first-line treatment; however, a substantial proportion continue to experience residual OSA after surgery or are not suitable surgical candidates. In these cases, Continuous Positive Airway Pressure (CPAP) therapy is the standard treatment. CPAP delivers pressurized air through a mask worn during sleep to keep the airway open. While CPAP is effective under optimal conditions, real-world effectiveness in pediatric populations is limited by low tolerance and adherence. Common challenges include discomfort related to the mask interface, claustrophobia, air pressure intolerance, and family burden associated with nightly device use.

High-Flow Nasal Cannula (HFNC) therapy has emerged as a potential alternative for treating pediatric OSA. HFNC delivers warmed, humidified air at high flow rates through soft nasal prongs and can generate positive airway pressure that supports upper airway patency. Compared with CPAP, HFNC may be perceived as less intrusive and more comfortable, which could improve adherence and overall treatment effectiveness. Preliminary physiologic studies and small clinical trials suggest that HFNC can reduce OSA severity; however, there is limited evidence comparing HFNC and CPAP in children, particularly over extended periods of use in home settings.

The CHOSA Trial was designed to address this evidence gap by directly comparing CPAP and HFNC in children with moderate-to-severe OSA who require non-surgical therapy. The study evaluates the real-world use of these therapies in the home environment, with a focus on treatment adherence as well as patient- and family-centered outcomes. By embedding the intervention within routine clinical care across multiple centers, the study aims to reflect typical pediatric sleep medicine practice and enhance the generalizability of its findings.

Participants receive comprehensive education and support to promote safe and effective use of their assigned therapy. Device setup, fitting, and optimization are performed by trained respiratory therapists, and treatment is titrated using standard sleep study procedures to ensure appropriate therapeutic settings. During the home treatment period, participants and caregivers receive ongoing clinical support consistent with usual care, including troubleshooting for comfort and usability concerns.