During this journey I have learned that standard-of-care is not necessarily practiced as well as we all think. We all have our own issues, but there are some things that should just be done in the interest of our patients. During the current pandemic, I have come to realize that many institutions did not have sufficient high flow nasal cannula systems to care for their patients and some were even reluctant to use them for x or y reason.
The European Society of Intensive Care Medicine (ESICM) nominated a panel of experts to develop guidelines for respiratory support using HFNC and their paper was published in November of 2020. They looked at creating 4 recommendations for the use of high flow nasal cannula. Those four recommendations included “use in patients with hypoxemic respiratory failure, following extubation, in the peri-intubation period, and postoperatively”. Ultimately you should read the article for yourself and not trust me. It’s free for you to download. Update 3/14/23: I have added some additional practice goodies you may find interesting.
Choosing the Flow on HFNC (Updated 3/14/23)
Li J, Albuainain FA, Tan W, Scott JB, Roca O, Mauri T. The effects of flow settings during high-flow nasal cannula support for adult subjects: a systematic review. Crit Care. 2023 Feb 28;27(1):78. doi: 10.1186/s13054-023-04361-5. PMID: 36855198; PMCID: PMC9974062.
Link to Article
Link to FULL FREE PDF
High Flow Recommendations from the European Society of Intensive Care Medicine
Hypoxemic Respiratory Failure: use high flow nasal cannula over conventional oxygen therapy
Following extubation: If you’re going to use conventional oxygen therapy, use HFNC instead if the patient was intubated for more than 24 hours and have high-risk features. If you would normally extubate to non-invasive ventilation, keep doing what you’re doing.
Peri-intubation: no recommendation provided. In my practice I sometimes reach for it if it’s likely going to be a dicey airway but most of the time I do not get a whole new setup if they don’t have the high flow nasal cannula system on their face from the get-go.
Post-operative in the CCU/CVICU: use HFNC instead of conventional oxygen therapy if the patient is high-risk or obese in the immediate post-op period. Don’t use HFNC prophylactically.
High Flow Recommendations from the European Society of Intensive Care Medicine (UPDATED 02/02/22)
Oczkowski S, Ergan B, Bos L, Chatwin M, Ferrer M, Gregoretti C, Heunks L, Frat JP, Longhini F, Nava S, Navalesi P, Uğurlu AO, Pisani L, Renda T, Thille AW, Winck JC, Windisch W, Tonia T, Boyd J, Sotgiu G, Scala R. ERS Clinical Practice Guidelines: High-flow nasal cannula in acute respiratory failure. Eur Respir J. 2021 Oct 28:2101574. doi: 10.1183/13993003.01574-2021. Epub ahead of print. PMID: 34649974.
Link to the Finalized Article
Link to FULL FREE PDF
8 Conditional Recommendations for high-flow nasal cannula in acute respiratory failure
“1. HFNC over COT in hypoxaemic ARF
2. HFNC over NIV in hypoxaemic ARF
3. HFNC over COT during breaks from NIV
4. either HFNC or COT in post-operative patients at low risk of pulmonary complications
5. either HFNC or NIV in post-operative patients at high risk of pulmonary complications
6. HFNC over COT in nonsurgical patients at low risk of extubation failure
7. NIV over HFNC for patients at high risk of extubation failure unless there are relative or absolute contraindications to NIV
8. trialling NIV prior to use of HFNC in patients with COPD and hypercapnic ARF.”
High Flow and ARDS
More recently, here is discussion that HFNC should be included as an oxygen delivery modality in ARDS. I’ve always felt this was but thankfully someone else put it in writing and published it in the blue journal. Dr. Lorraine Ware makes this argument which I completely agree with.
Disclaimer: I am a consultant for a high flow nasal cannula company but I am not being compensated for the contents of this post.
Click here for more posts on high flow and NIV. If you want to learn about high-flow and COPD CLICK HERE.
Citations for the High Flow Guidelines
Rochwerg B, Einav S, Chaudhuri D, Mancebo J, Mauri T, Helviz Y, Goligher EC, Jaber S, Ricard JD, Rittayamai N, Roca O, Antonelli M, Maggiore SM, Demoule A, Hodgson CL, Mercat A, Wilcox ME, Granton D, Wang D, Azoulay E, Ouanes-Besbes L, Cinnella G, Rauseo M, Carvalho C, Dessap-Mekontso A, Fraser J, Frat JP, Gomersall C, Grasselli G, Hernandez G, Jog S, Pesenti A, Riviello ED, Slutsky AS, Stapleton RD, Talmor D, Thille AW, Brochard L, Burns KEA. The role for high flow nasal cannula as a respiratory support strategy in adults: a clinical practice guideline. Intensive Care Med. 2020 Dec;46(12):2226-2237. doi: 10.1007/s00134-020-06312-y. Epub 2020 Nov 17. PMID: 33201321; PMCID: PMC7670292.
Link to Article
Link to FULL FREE PDF
UPDATE on 02/02/22
Oczkowski S, Ergan B, Bos L, Chatwin M, Ferrer M, Gregoretti C, Heunks L, Frat JP, Longhini F, Nava S, Navalesi P, Uğurlu AO, Pisani L, Renda T, Thille AW, Winck JC, Windisch W, Tonia T, Boyd J, Sotgiu G, Scala R. ERS Clinical Practice Guidelines: High-flow nasal cannula in acute respiratory failure. Eur Respir J. 2021 Oct 28:2101574. doi: 10.1183/13993003.01574-2021. Epub ahead of print. PMID: 34649974.
Link to Article
Link to FULL FREE PDF
Ware LB. Go with the Flow: Expanding the Definition of ARDS to Include High Flow Nasal Oxygen. Am J Respir Crit Care Med. 2022 Jan 10. doi: 10.1164/rccm.202112-2727ED. Epub ahead of print. PMID: 35007489.
Link to Article
Link to FULL FREE PDF
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