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Thoracic surgery patients are at high-risk for adverse pulmonary outcomes. Heated humidified high-flow nasal cannula oxygen (HHFNC O2) may decrease such events. We hypothesized that patients randomized to prophylactic HHFNC O2 would develop fewer pulmonary complications compared to conventional O2 therapy.Fifty-one patients were randomized to HHFNC O2 vs. conventional O2. The primary outcome was a composite of postoperative pulmonary complications. Secondary outcomes included oxygenation and length of stay. Continuous variables were compared with t-test or Mann-Whitney-U test, categorical variables with Fisher's Exact test.There were no differences in postoperative pulmonary complications based on intention to treat [two in HHFNC O2 (n = 25), two in control (n = 26), p = 0.680], and after exclusion of patients who discontinued HHFNC O2 early [one in HHFNC O2 (n = 18), two in control (n = 26), p = 0.638]. Discomfort from HHFNC O2 occurred in 11/25 (44%); 7/25 (28%) discontinued treatment.Pulmonary complications were rare after thoracic surgery. Although HHFNC O2 did not convey significant benefits, these results need to be interpreted with caution, as our study was likely underpowered to detect a reduction in pulmonary complications. High rates of patient-reported discomfort with HHFNC O2 need to be considered in clinical practice and future trials.Pulmonary complications were rare after thoracic surgery.Patient-reported discomfort was more frequent with the use of HHFNC O2.This pilot study did not indicate a beneficial effect of prophylactic HHFNC O2.Larger samples are necessary to definitively ascertain benefits of HHFNC O2.