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Heated and humidified high-flow nasal oxygen in adults: Practical considerations and potential applications

Heated and humidified high-flow nasal oxygen in adults: Practical considerations and potential applications
Literature review current through: Jan 2024.
This topic last updated: May 02, 2023.

INTRODUCTION — Oxygen is typically delivered via low-flow systems (eg, nasal cannulae or masks) or high-flow systems (eg, Venturi masks, nonrebreathers). Such conventional systems do not deliver a reliable fraction of inspired oxygen, and are generally poorly tolerated for prolonged periods due to inadequate warming and humidification of inspired gas. While commonly used in infants, the development of newer systems for adults that reliably deliver warmed and humidified oxygen at high flows through nasal cannulae (HFNC) has led to the increasing use of HFNC.

This topic review discusses the practical application and clinical uses of HFNC in adults. Oxygen delivery systems for infants and children are discussed separately. (See "Continuous oxygen delivery systems for the acute care of infants, children, and adults".)

MECHANISMS OF CLINICAL BENEFIT — The mechanisms by which oxygen delivered via high-flow nasal cannulae (HFNC) offers benefit are shown in the table (table 1) [1]. The major end organ effects are improved comfort and oxygenation. However, whether such effects translate into a meaningful clinical benefit (eg, reduced mortality or intubation rates) is unknown. Mechanisms include:

Small pliable nasal prongs – HFNC nasal prongs are generally soft and pliable (picture 1). Consequently, several studies have reported improved patient comfort with HFNC when compared with conventional low-flow oxygen delivered through nasal cannulae or high-flow oxygen delivered through a face mask [2-4].

Warming and humidification of secretions – Warming inspired oxygen and heating it to core temperature is more effective at high flow rates (typically >40 L/minute) than low flow rates. Thus, HFNC is better at heating and humidifying inspired oxygen than conventional high-flow systems such as Venturi masks or nonrebreathers (flow rate typically 10 to 15 L/minute) or low-flow systems (flow rates typically <10 L/minute). Increased humidification results in increased water content in mucous, which can facilitate secretion removal and may also decrease the work of breathing and avoid airway desiccation and epithelial injury [5,6].

Washout of nasopharyngeal dead space – Washout of upper airway dead space from the delivery of a large amount of oxygen can improve the efficiency of ventilation and enhance oxygen delivery [7-9]. Thus, improved washout with HFNC, when compared with other oxygen delivery systems, permits a higher fraction of minute ventilation to participate in alveolar gas exchange.

Continuous positive airway pressure (CPAP) effect – Several studies in adults have shown that, similar to infants and neonates, HFNC increases nasopharyngeal airway pressure that peaks at the end of expiration (ie, "PEEP effect") (figure 1) [10-16]. This "PEEP effect" can potentially unload auto-PEEP (if present), decrease work of breathing, and enhance oxygenation in patients with alveolar filling diseases such as congestive heart failure or the acute respiratory distress syndrome. As flow increases, nasopharyngeal pressure increases (ie, a dose effect) [10]. The CPAP effect is greatest with the mouth closed. In general, every increase of 10 L/minute of flow yields approximately 0.7 cm H2O of airway pressure when the mouth is closed and 0.35 cm H2O when the mouth is open [11]. Thus, the effect is mild to moderate, at best.

High flow rates – High flow rates result in minimal entrainment of room air when HFNC is used; this results in more accurate delivery of oxygen, especially when compared with conventional delivery systems. Patients in respiratory distress generate high inspiratory flow rates that exceed flow rates of standard oxygen equipment, resulting in entrainment of room air and a reduction in the delivery of the set fraction of inspired oxygen (FiO2). The rate of flow in HFNC generally exceeds that of the patient, entraining very little room air and resulting in an FiO2 that is more reliably delivered [12,17,18]. However, similar to conventional systems, open mouth breathing or breathing during exercise will mitigate this advantage somewhat. High flow rates have also been shown to result in an improved breathing pattern by increasing tidal volume and decreasing respiratory rate [16,19].

Decreased inspiratory effort – Increasing flow rates decreases inspiratory effort, which is a linear [20]. Carbon dioxide clearance is usually obtained at lower flow rates.

PHYSICAL APPLICATION AND SETTINGS — High-flow nasal cannula (HFNC) is being increasingly used to deliver oxygen to patients (picture 1). There are no set recommendations for its practical application; thus, the suggestions below reflect our practice. Although HFNC can be administered on an unmonitored floor, in our opinion, it is best applied in a monitored setting such as the intensive care unit, intermediate care floor, or emergency department [9,21]. Our preference is based upon the rationale that patients in need of HFNC are at high risk of severe respiratory failure or mechanical ventilation, in which case a closely monitored setting is often needed. However, once the patient is improving and on a trajectory of reduced oxygen requirements (eg, 50 L/minute at 60 percent fraction of inspired oxygen [FiO2]), HFNC may be delivered in a less monitored setting.

Oxygen flows from the source, is heated and humidified, and is then delivered to the patient through wide bore nasal cannulae, which are generally made of softer, more pliable plastic than cannulae for low-flow systems (picture 1). The cannulae fit snugly into the nares and are held in place with a head strap.

Two parameters need to be set:

The flow rate

The FiO2

We prefer to set the flow rate first, typically at 20 to 35 L/minute (range 5 to 60 L/minute). The FiO2 (range 21 to 100 percent) is next set to target a desired peripheral oxygen saturation. The flow rate can subsequently be increased in 5 to 10 L/minute increments if the respiratory rate fails to improve, oxygenation fails to adequately improve, or breathing remains labored. Increasing the flow rate and FiO2 will both result in improved peripheral oxygen saturation; we prefer to maximize the flow rate first in an attempt to keep the FiO2 ≤60 percent; however, an increase in FiO2 may be necessary to achieve adequate oxygenation.

HFNC is generally well tolerated and can be administered for prolonged periods (eg, days). Patients switch to conventional low-flow nasal cannula system once the flow rate reaches ≤20 L/minute and FiO2 ≤50 percent.

In most cases, aerosolized medication is given directly to the patients with the HFNC in place using an oral mouthpiece (ie, nebulized medication is not delivered through HFNC equipment). However, aerosol delivery with HFNC in place is poorly studied and may not be guaranteed at high flows.

INDICATIONS — The approach in this section generally follows that set out by clinical practice guidelines [22].

General principles of application — Oxygen delivered through high-flow nasal cannulae (HFNC) has been successfully used in several settings. However, the indications are not absolute, with much of the proven benefit being subjective and physiologic. Most data to support it are derived from observational studies using physiologic outcomes or from randomized trials studying heterogeneous populations (eg, preintubation, postextubation, surgical, medical) that include a variety of comparators (eg, low-flow oxygen, noninvasive ventilation [NIV]). In general, results have been mixed and fail to consistently demonstrate an improvement in clinically meaningful outcomes (eg, mortality, intubation rates, length of stay). As an example, a meta-analysis of 13 randomized trials of patients deemed at risk of respiratory failure and intubation (postoperative and postextubation respiratory failure and acute respiratory failure of medical origin) failed to demonstrate a decrease in the rate of intubation (10 versus 16 percent) or mortality (6 versus 8 percent) [23].

Despite these limited data, HFNC is frequently used in practice. As a general principle, in patients with severe hypoxemic respiratory failure (eg, partial arterial pressure of oxygen:fraction of inspired oxygen [PaO2:FiO2] ratio <300 mmHg), we suggest that HFNC is an alternative to the following:

Other high-flow oxygen systems (eg, simple, Venturi, or nonrebreather oxygen masks) – HFNC is often better tolerated than oxygen masks due to enhanced patient comfort, reliable delivery of FiO2, and the potential reduction in the work of breathing. Choosing between these systems and HFNC should be individualized and depends upon clinician preference, institutional availability, patient comfort, and severity of hypoxemia. (See "Continuous oxygen delivery systems for the acute care of infants, children, and adults" and "Continuous oxygen delivery systems for the acute care of infants, children, and adults", section on 'Nasal cannula' and "Continuous oxygen delivery systems for the acute care of infants, children, and adults", section on 'Face masks'.)

NIV – HFNC may be used as an alternative to NIV or for the provision of adequate oxygenation during breaks from NIV. Choosing among these options depends upon factors including need for ventilation and positive end-expiratory pressure (PEEP) as well as patient preference and tolerance of the NIV mask. For example, HFNC is unlikely to provide sufficient PEEP for those who need it (eg, moderate to severe acute respiratory distress syndrome [ARDS]) and cannot be used for those who require NIV for ventilation (ie, hypercapnic hypoxemic respiratory failure due to hypoventilation). It is also unlikely to reduce the work of breathing as effectively as NIV. (See "Noninvasive ventilation in adults with acute respiratory failure: Benefits and contraindications".)

HFNC does not have a role to play for those who are sufficiently oxygenated with low-flow nasal cannulae or those with an indication for immediate intubation (which includes failure of NIV).

Concerns have been raised regarding whether the use of HFNC can potentially delay necessary intubation and worsen outcomes [24]. As a result, when HFNC is used, clinicians should remain vigilant to signs of respiratory failure that necessitate intubation and mechanical ventilation. These include additional elevations of respiratory rate, the presence of thoracoabdominal asynchrony as early as 15 minutes after the beginning of HFNC therapy, and the failure to adequately improve oxygenation within an hour after the initiation of HFNC [7]. In addition, relatively late failure (ie, more than six hours after initiation of HFNC) is associated with a higher mortality than earlier failure, suggesting this time frame to be a useful one for careful re-examination of how a patient is doing clinically [25].

Patients who are not tachypneic may succeed with HFNC despite a relatively high FiO2. The ROX index (peripheral arterial oxygen saturation/fraction of inspired oxygen [expressed as a percentage]/respiratory rate) may help guide clinicians in this regard. In one small series, a ROX of >4.88 at 2, 6, and 12 hours post-initiation of HFNC indicated a less likely need for subsequent endotracheal intubation. The ROX index has only moderate discriminatory power but may be useful in patients with acute hypoxemic respiratory failure due to both pneumonia and other causes as well as at earlier timepoints, including one hour after HFNC initiation [26]. While meta-analyses suggest some validity to the utilization of the ROX index in predicting success or failure with the use of HFNC, it is clear that the ROX index cannot be used in isolation and must be augmented by clinical judgement [27,28].

Medical patients with severe hypoxemic respiratory failure — The main use of HFNC is to provide a relatively high FiO2 to patients with severe nonhypercapnic hypoxemic respiratory failure from medical causes. These data are described separately:

(See "Evaluation and management of the nonventilated, hospitalized adult patient with acute hypoxemia", section on 'Humidified, high-flow oxygen delivered via nasal cannulae (HFNC)'.)

(See "COVID-19: Respiratory care of the nonintubated hypoxemic adult (supplemental oxygen, noninvasive ventilation, and intubation)", section on 'Noninvasive modalities'.)

(See "Noninvasive ventilation in adults with acute respiratory failure: Benefits and contraindications", section on 'Hypoxemic nonhypercapnic respiratory failure not due to ACPE'.)

Others — HFNC has been used in several other settings including for intubation and extubation support as well as for the treatment and prevention of postoperative respiratory failure and for oxygenating patients during weaning trials or bronchoscopy.

Postextubation support — HFNC has been employed as an adjunct support measure in patients following extubation. Data that discusses the role of HFNC in this population are described separately. (See "Extubation management in the adult intensive care unit", section on 'Low-flow versus high-flow oxygen' and "Extubation management in the adult intensive care unit", section on 'High-flow oxygen via nasal cannulae'.)

Postoperative respiratory failure — HFNC has also been used successfully in the treatment and prevention of postoperative respiratory failure, the details of which are discussed elsewhere. (See "Overview of the management of postoperative pulmonary complications", section on 'Postoperative respiratory failure'.)

Intubation support — Most experts use conventional systems (high-flow oxygen masks and low-flow nasal cannulae) and bag-mask ventilation to deliver oxygen prior to intubation; the bag-mask or oxygen mask is temporarily removed (sometimes leaving cannulae in place) for the intubation procedure itself. Although not routine, HFNC is an acceptable way to provide oxygen to patients undergoing intubation, both before (preoxygenation) and during the procedure (to prevent desaturation). Importantly, no delay in preoxygenation should occur while waiting for HFNC to be set up (which takes a few minutes), during which time, preoxygenation using other available means should occur. In a meta-analysis of patients receiving HFNC or standard oxygen therapy during apneic ventilation prior to intubation, HFNC was noninferior to standard oxygen therapy in patients with a PaO2:FiO2 ratio <200 but resulted in a decreased incidence of severe hypoxemic events among less hypoxemic patients whose PaO2:FiO2 ratios were above 200 [29]. (See "Airway management for induction of general anesthesia", section on 'Preoxygenation' and "Rapid sequence induction and intubation (RSII) for anesthesia", section on 'Preoxygenation'.)

Data are conflicting regarding the value of HFNC for preoxygenation prior to intubation [30-33]:

Several trials have shown improved oxygenation when HFNC strategies are used. One randomized single center study compared four minutes of preoxygenation with HFNC (100 percent FiO2 at 60 L/minute) together with concomitant NIV (10 cm H2O pressure support ventilation and 5 cm H2O PEEP) with NIV alone prior to intubation. HFNC/NIV resulted in higher peripheral oxygen saturations (100 versus 96 percent) and fewer patients with episodes of desaturation below 80 percent (0 versus 21 percent) [30]. Similar results were reported in a study of 101 patients, where compared with a nonrebreather mask, peripheral oxygen saturations at the end of the preoxygenation period were higher with HFNC (100 versus 94 percent) and fewer patients exhibited episodes of severe hypoxemia (2 versus 14 percent) [31].

In contrast, in a multicenter study of 124 patients undergoing intubation who had severe hypoxemia (PaO2:FiO2 ratio <300 mmHg, respiratory rate >30 breaths/minute, and a FiO2 >50 percent to achieve a saturation of >90 percent), HFNC did not reduce the lowest saturation during intubation when compared with preoxygenation using a conventional high-flow oxygen face mask [32].

A meta-analysis has shown no benefit among intensive care unit (ICU) patients associated with the use of HFNC in the peri-intubation period in hypoxemia, apnea time, or complications when compared with conventional oxygen therapy, making HFNC an acceptable, though not superior, choice in this clinical setting [34].

HFNC has also been studied as a method of oxygenation during intubation in the ICU. In a multicenter study of 150 critically ill patients who were rendered apneic for intubation, HFNC with a FiO2 of 100 percent at 15 L/minute delivered during laryngoscopy resulted in higher saturations when compared with usual care (ie, patients intubated without supplemental oxygen who had not been made apneic for the procedure; 90 versus 92 percent) [33].

The use of high flow nasal oxygen for airway management for anesthesia is discussed separately. (See "Preoxygenation and apneic oxygenation for airway management for anesthesia".)

Miscellaneous — Patients who are weaning via tracheostomy may potentially benefit from HFNC.

In a randomized crossover trial, when compared with oxygen delivered at 15 L/minute through a T-piece, patients receiving HFNC at 50 L/minute had higher saturations for a given FiO2, which permitted a lower FiO2 to be administered [35]. No clinical outcomes were analyzed in this feasibility study. (See "Management and prognosis of patients requiring prolonged mechanical ventilation".)

In another trial HFNC was successfully used to wean patients off tracheostomy more rapidly when compared with a more conventional trial of capping. This trial is discussed separately. (See "Tracheostomy: Postoperative care, maintenance, and complications in adults", section on 'Techniques'.)

HFNC has also been used to successfully oxygenate hypoxemic patients undergoing fiberoptic bronchoscopy [36-40]. Such patients are at high risk of respiratory decompensation requiring ventilator support as a consequence of the procedure. In a randomized trial of 40 patients with hypoxemic respiratory failure who underwent bronchoscopy, there was no difference in peripheral oxygen saturation between patients who were supported with NIV and patients supported with HFNC [37]. One HFNC patient deteriorated and required NIV; however, three NIV patients required endotracheal intubation within 24 hours of bronchoscopy versus one in the HFNC group. In contrast, another randomized trial of 36 patients reported improved oxygenation in those receiving HFNC during bronchoscopy compared with standard oxygenation measures [38]. In another study of patients undergoing fiberoptic bronchoscopy, there were fewer hypoxemic events, a higher nadir saturation, and a higher PaO2 at the end of the procedure than was seen in patients receiving nasal cannula oxygen [39]. (See "Flexible bronchoscopy in adults: Preparation, procedural technique, and complications", section on 'Equipment and supplies'.)

CONTRAINDICATIONS AND COMPLICATIONS — Most patients tolerate oxygen delivery via high-flow nasal cannula (HFNC). Contraindications or complications are rare in adults.

Contraindications to HFNC include abnormalities or surgery of the face, nose, or airway that preclude an appropriate-fitting nasal cannula. Some experts avoid HFNC in those following upper airway surgery to avoid the theoretical risk that the high pressure may precipitate a venous thromboembolism.

Complications of HFNC include abdominal distension, aspiration, and, rarely, barotrauma (eg, pneumothorax). However, the risk of barotrauma is likely lower with HFNC than with noninvasive ventilation or mechanical ventilation following endotracheal intubation. (See "Diagnosis, management, and prevention of pulmonary barotrauma during invasive mechanical ventilation in adults".)

Since the definition of acute respiratory distress syndrome (ARDS) is dependent upon calculating the partial arterial pressure of oxygen to fraction of inspired oxygen (PaO2:FiO2) ratio, some experts have raised concern that the recognition of ARDS may be adversely impacted by HFNC because improvements in oxygenation seen in mild ARDS with HFNC may result in a PaO2:FiO2 ratio below the threshold of diagnosis, without having accounted for the positive end-expiratory effect of HFNC (see "Acute respiratory distress syndrome: Clinical features, diagnosis, and complications in adults", section on 'Clinical diagnosis') [41]. However, this theoretical disadvantage may be mitigated by the potential beneficial effects on improving ventilator-induced lung injury and thereby the progression of hypoxemic respiratory failure to ARDS [42].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Assessment of oxygenation and gas exchange".)

SUMMARY

Mechanism of action – Systems that reliably deliver warmed and humidified oxygen at high flows through nasal cannulae (HFNC) have been developed and are being increasingly used for oxygenation in adults. Advantages of HFNC compared with conventional oxygen delivery systems include enhanced comfort, increased humidification of secretions to facilitate expectoration, washout of nasopharyngeal dead space to improve efficiency of ventilation, provision of a small positive airway pressure effect, and high flow rates to minimize the entrainment of room air for reliable delivery of fraction of inspired oxygen (FiO2). (See 'Mechanisms of clinical benefit' above.)

Application – HFNC is best applied in a monitored setting such as the intensive care unit, intermediate care floor, or emergency department. Oxygen is delivered to the patient through wide bore nasal cannulae (picture 1). We prefer to set the flow rate first, typically at 20 to 35 L/minute (range 5 to 60 L/minute). The FiO2 (range 21 to 100 percent) is next set to target a desired peripheral oxygen saturation. Further adjustments of both settings can be made depending upon the initial clinical response. HFNC can be administered for prolonged periods (eg, days) and patients can be switched to conventional low-flow nasal cannulae once the flow rate reaches ≤20 L/minute and FiO2 ≤50 percent. (See 'Physical application and settings' above.)

General principles of application – HFNC has been successfully used in several settings. However, the indications are not absolute, with much of the proven benefit being subjective and physiologic. In patients with severe hypoxemic respiratory failure, we suggest that HFNC is an alternative to other high-flow systems and noninvasive ventilation. Choosing between these systems should be individualized and depends upon clinician preference, institutional availability, patient preference, severity of hypoxemia, and need for ventilation and positive end-expiratory pressure (PEEP). (See 'General principles of application' above.)

Indications – HFNC has several indications (see 'Indications' above):

The most common indication is patients with severe acute respiratory failure (eg, partial arterial pressure of oxygen to fraction of inspired oxygen [PaO2:FiO2] ratio <300 mmHg) from medical conditions (eg, pneumonia). These data are discussed in detail separately.

-(See "Evaluation and management of the nonventilated, hospitalized adult patient with acute hypoxemia", section on 'Humidified, high-flow oxygen delivered via nasal cannulae (HFNC)'.)

-(See "COVID-19: Respiratory care of the nonintubated hypoxemic adult (supplemental oxygen, noninvasive ventilation, and intubation)", section on 'Noninvasive modalities'.)

-(See "Noninvasive ventilation in adults with acute respiratory failure: Benefits and contraindications", section on 'Hypoxemic nonhypercapnic respiratory failure not due to ACPE'.)

Less commonly, HFNC has been used as an oxygenation strategy in the following groups, although the data in these population are less robust:

-Patients at risk of extubation failure. (See "Extubation management in the adult intensive care unit", section on 'Low-flow versus high-flow oxygen' and "Extubation management in the adult intensive care unit", section on 'High-flow oxygen via nasal cannulae'.)

-Patients undergoing intubation. (See "Airway management for induction of general anesthesia", section on 'Preoxygenation' and "Rapid sequence induction and intubation (RSII) for anesthesia", section on 'Preoxygenation'.)

-Patients at risk of or who have postoperative respiratory failure. (See "Overview of the management of postoperative pulmonary complications", section on 'Postoperative respiratory failure'.)

-Patients undergoing weaning trials and bronchoscopy. (See 'Miscellaneous' above.)

Contraindications – Contraindications to HFNC include abnormalities or surgery of the face, nose, or airway that preclude an appropriate-fitting nasal cannula. Complications are rare and include abdominal distension, aspiration, and rarely barotrauma. (See 'Contraindications and complications' above.)

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References

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