Review Article
High-Flow Nasal Cannula Oxygen in Adult Patients: A Narrative Review

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Abstract

High-flow nasal cannula oxygen (HFNC) is a relatively new therapeutic innovation being used in adults with severe respiratory disease. It delivers heated humidified oxygen through short nasal prongs and supplies much higher flow rates than traditional nasal cannula systems. These higher flows match patient flow demands better, reduce anatomic dead space and provide a slightly positive pressure in the upper airway. Randomized trials, nonrandomized prospective trials and case series using HFNC in adults were identified in the PubMed, Google Scholar and Cochrane databases for the period of June 1981 to December 2013. Fifteen studies meeting our inclusion criteria were analyzed; 5 were randomized controlled studies. These studies included 943 patients managed in intensive care units. Common clinical diagnoses included postoperative status, cancer and pneumonia. These studies demonstrated that HFNC provided better or comparable oxygenation when compared with conventional face masks and nasal cannulas. Side effects included epistaxis, nasal discomfort and dryness. No unexpected side effects were reported in the studies reviewed. Current studies demonstrate that HFNC can improve oxygenation adults with hypoxemic respiratory failure. in some patients, it is superior to traditional oxygen delivery systems and may obviate the need for positive pressure ventilation. More studies are needed to compare HFNC with noninvasive ventilation.

Section snippets

Study Objectives

The goal of this review is to summarize the relevant medical literature on the use of HFNC in adults. Several reviews are available for the pediatric population, and these articles will not be included in our analysis.1 We will try to answer the following key questions about the use of HFNC in adults.

  • 1.

    What are the usual physiological changes seen in patients with the use of HFNC?

  • 2.

    In which patients and clinical settings has HFNC been studied?

  • 3.

    Does it help patients avoid the use of NIV or intubation

RESULTS

Fifteen studies met our inclusion criteria and were analyzed. Five studies were randomized studies (Table 1), 5 were nonrandomized prospective studies (Table 2) and 5 were retrospective cohort studies. These studies included 943 patients managed in intensive care units (ICUs) (9 studies), emergency departments (1 study), postoperative units (4 studies) and inpatient hospital services (1 study also with some ICU patients). Frequent diagnoses included postoperative patients (410 patients), cancer

DISCUSSION

HFNC provides higher gas flow rates with higher FiO2s than conventional O2 supplementation with nasal cannulas, face masks, Venturi masks and non-rebreathing masks. Therefore, these devices increase O2 delivery and improve PaO2 in hypoxemic patients and potentially obviate the need for positive pressure ventilation. In addition, the high flow rates can create a slightly positive pressure in the upper airway similar to nasal CPAP.2., 3. This technique has been widely studied in pediatric

CONCLUSIONS

Studies with HFNC in adults have demonstrated that this technology can provide supplemental oxygen at higher flows and FiO2 than conventional O2 delivery methods in patients with acute hypoxemic respiratory failure. These studies demonstrate that HFNC increases the PaO2 in these patients, is well tolerated and has few side effects. However, it is important to conduct studies that are adequately powered to determine which patient groups benefit the most with HFNC. In particular, clinicians need

RECOMMENDATIONS

  • 1.

    HFNC delivery systems are most useful in patients with hypoxemic respiratory failure who are difficult to oxygenate with face masks and/or nasal cannulas (Figure 2). These patients must have an adequate respiratory drive and muscle strength to maintain reasonable minute ventilations and keep their PaCO2 from increasing rapidly.

  • 2.

    Patients should have a reduction in respiratory rate and dyspnea and should have an increase in PaO2 or O2 saturation after switching to HFNC.

  • 3.

    Potential candidates include

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  • R.L. Parke et al.

    A preliminary randomized controlled trial to assess effectiveness of nasal high-flow oxygen in intensive care patients

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      Citation Excerpt :

      Flow, on the other hand, is set equal to or greater than the patient's inspiratory flow demand and titrated to the work of breathing [16]. But the role of HFNO in ARF is an open question, and the recent reviews [15,17] of HFNO have not dealt with this in detail. Although the results of RCTs have been inconsistent regarding escalation of respiratory support, this meta-analysis shows that there is a trend toward improved outcomes with HFNO compared with standard oxygen therapy, which is not statistically significant.

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    The authors have no financial or other conflicts of interest to disclose.

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