This is a prospective, randomized, unblinded trial of trauma patients in the ICU who are identified as being at a high risk to develop acute respiratory failure.

We hope that this study will help the study team to identify how best to use a more aggressive respiratory treatment strategy in a high risk trauma population (thoracic trauma or trauma patients requiring thoracic surgery, spine surgery, or open abdominal procedures) to try and decrease the need for intubation with mechanical ventilation.

All patients consented will be randomly assigned into one of three groups: nasal cannula (control group, our current standard of care), high-flow nasal cannula, high-flow nasal cannula plus noninvasive ventilation.

After obtaining consent, patient will be randomized to interventions 1:1:1 within each of two groups: patients admitted to the ICU without being intubated OR intubated patients undergoing an extubation.

Randomization will be managed through RedCap. After consent, the treating clinician will log into RedCap to obtain the patient's treating assignment.

The primary outcome of interest is failure of conservative ventilation intervention in prevention of initial intubation or prevention of reintubation.

A chart review of all enrolled patients will be done quarterly to assess morbidity, mortality, and outcomes.

No placebo will be used as all qualifying patients will be placed on nasal cannula, high-flow nasal cannula, or high-flow nasal cannula plus noninvasive ventilation. All other treatments will be standard of care.

Participants in the study will continue until the patient is discharged from the trauma ICU.

The study will end when the last person enrolled has been discharged from the trauma ICU. If patient's participation ends prematurely, available data will be entered into the database and evaluated appropriately.

This study will take place at the OU Medical Center (OUMC) among patients admitted to the Trauma Intensive Care Unit.

Consent for study enrollment will take place at OUMC during discussion with physician providing trauma care and the patient, family member, or next of kin consenting for the study.

The following data will be collected and recorded: Supplemental oxygen requirements, Date/Time of arrival, Date/Time of Admission to ICU, Date/Time of intubation procedure, Date/Time of extubation, Ventilator settings, Duration of intubation, Comorbidities, PaCO2 values, PaO2 values, Vital signs at arrival and at admission to ICU, Age,Gender, Weight, Height, BMI, Traumatic injuries, Diagnosis, Past medical history/medical co-morbidities, Glasgow coma scale, Oxygen saturation, Negative inspiratory force score, Rapid shallow breathing index score, Pulmonary treatments, including an intolerance to therapy, Injury Severity Score (ISS) and/or Abbreviated Injury Scale (AIS).

Inclusion Criteria:

1. Adults at least 18 years of age
2. Admission to an intensive care unit by the trauma surgery service
3. Trauma patients receiving any respiratory therapies
4. High risk patients, including intubation, post-operative, chronic cardiac or pulmonary comorbidities
5. Thoracic injuries, including rib fractures, sternal fractures, spinal fractures, pulmonary contusions, pneumothorax, hemothorax, diaphragm injury
6. Postoperative from thoracic surgery
7. Postoperative from spine surgery in patients without spinal cord injury
8. Abdominal injuries requiring open abdominal surgery
9. No contraindications to using high flow nasal cannula or noninvasive ventilation

Exclusion Criteria:

1. Contraindication to using high flow nasal cannula or noninvasive ventilation
2. Intolerance of pulmonary therapies
3. No one able to give informed consent
4. Long-term treatment with noninvasive ventilation prior to hospital admission
5. "Do not intubate" order at time of extubation
6. Unplanned extubation (accidental or self-extubation)
7. Age < 18 years of age
8. Traumatic brain injury with GCS < 8
9. Spinal cord injury
10. Chronic neuromuscular disease
11. Sinus precautions due to facial/sinus fractures