Volume 83, December 2025, 101699Author links open overlay panelSection snippetsLimited sample size and study period

The study reports only 12 patients receiving NHF out of 898 ED presentations, representing 1.3 % of the total cohort [1]. Such a small subgroup substantially limits statistical power and undermines the reliability of effect estimates. Furthermore, the use of two isolated 12-hour collection periods cannot capture the temporal and seasonal variability of respiratory illness, raising concerns about representativeness. Broader sampling across heterogeneous conditions, different seasons, including

Lack of individualized NHF management

The absence of temperature titration and the near-uniformity of flow and FiO2 settings suggest that NHF therapy was delivered in a standardized rather than individualized manner. Given that the clinical benefits of NHF depend on tailored titration to patient physiology, this management approach may explain the lack of observed improvement in respiratory parameters. Moreover, important contextual details—such as whether nurses or physicians adjusted NHF settings, or whether staff had received

Outcome interpretation and confounding

The authors report that NHF patients had significantly longer hospital lengths of stay (LOS). However, this interpretation does not adequately account for confounding by baseline illness severity, comorbidities, or triage category [3,4]. Patients selected for NHF may already represent a higher-acuity subgroup. Without risk adjustment, the finding risks misattribution, suggesting NHF increases LOS when it may simply be a marker of greater disease burden. A more rigorous analysis with

Escalation and discontinuation data

More than half of the reasons for discontinuation were categorized as “unknown,” and only one escalation event occurred in the NHF group [1]. With such incomplete and minimal data, inferences regarding escalation rates remain tenuous. Furthermore, the suggestion that NHF requires “less escalation” than other modalities seems overstated in light of the very small numbers. Future studies should ensure systematic documentation of escalation triggers, discontinuation reasons, and patient tolerance.

External validity and generalisability

Although the study is presented as real-world evidence, the limited geographic scope (four New Zealand EDs), the narrow observation windows, and the absence of longer-term outcomes such as 30-day mortality or readmission constrain external validity. ED populations are highly heterogeneous across countries, with differences in comorbidity patterns, staffing models, and resource availability. Therefore, extrapolating these findings to international contexts should be done with caution. The

Implications for emergency nursing practice

While the study rightly highlights the role of ED nurses in delivering NHF therapy, it does not fully address the educational and operational challenges associated with its implementation. NHF requires active titration and close monitoring, yet the study provides no insights into nurse workload, training, or decision-making autonomy. For the findings to inform nursing practice, greater attention must be paid to the human factors, protocols, and institutional policies that underpin safe and

Conclusion

In conclusion, O’Donnell et al. have initiated an important discussion on the role of NHF in the ED. However, methodological constraints, limited sample size, lack of individualized titration, incomplete escalation data, and limited external validity significantly restrict the interpretability of their findings. Future studies should adopt adequately powered, multicenter, longitudinal designs, ideally across different seasons, to capture the variability of respiratory presentations.

CRediT authorship contribution statement

Esra Türe: Conceptualization, Methodology, Validation, Visualization, Writing – original draft, Writing – review & editing.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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