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• W2421730782 abstract "Key points•High-flow nasal oxygen therapy (HFNOT) provides a valuable triad of humidity, high FIO2, and improved patient compliance.•It reduces heat and moisture loss from the airway, reduces anatomical dead space, provides PEEP, and improves oxygenation.•There is increasing evidence for its use in acute respiratory failure, as an aid to preoxygenation, in the management of the difficult airway and during bronchoscopy.•HFNOT can be useful in preventing postoperative respiratory failure.•Cautions for its use are similar to those for non-invasive facemask positive pressure ventilation. •High-flow nasal oxygen therapy (HFNOT) provides a valuable triad of humidity, high FIO2, and improved patient compliance.•It reduces heat and moisture loss from the airway, reduces anatomical dead space, provides PEEP, and improves oxygenation.•There is increasing evidence for its use in acute respiratory failure, as an aid to preoxygenation, in the management of the difficult airway and during bronchoscopy.•HFNOT can be useful in preventing postoperative respiratory failure.•Cautions for its use are similar to those for non-invasive facemask positive pressure ventilation. High-flow nasal oxygen therapy (HFNOT) is increasingly used as part of both ward-based and critical care management of respiratory failure. Respiratory failure is distressing for patients and treatment modalities currently in use may be associated with discomfort from upper airway drying, tightly fitting facemasks, and resultant complications such as skin breakdown. Invasive ventilation is also associated with a number of complications including ventilator-associated pneumonia. The ability of nasal cannulae to provide positive pressure to the airways was first noted in neonates, and it is in this patient group that this therapeutic effect was first used. A similar continuous positive airway pressure (CPAP) effect, with higher flows, was noted in adults1Parke R McGuinness S Eccleston M Nasal high-flow therapy delivers low level positive airway pressure.Br J Anaesth. 2009; 103: 886-890Crossref PubMed Scopus (325) Google Scholar and from here, HFNOT was developed.2Gotera C Diaz Lobato S Pinto T Winck JC Clinical evidence on high flow oxygen therapy and active humidification in adults.Rev Port Pneumol. 2013; 19: 217-227Crossref PubMed Scopus (15) Google Scholar HFNOT provides warmed, humidified gases at flows of up to 60 litre min−1, with inspired oxygen concentrations of up to 100%. The use of HFNOT is well validated in neonatal populations and the body of evidence for its use in adults is rapidly growing. There are several different devices available for the provision of high flow, humidified oxygen via nasal cannulae. The devices consist of nasal cannulae with standard sized or wide-bore prongs connected to an oxygen flow meter with an air–oxygen gas blender and gas analyser. They offer maximum gas flow rates of between 40 and 60 litre min−1, depending on the device. A heating system and humidifier allows delivery of gases at temperatures of between 33 and 43°C and 95–100% humidity (Table 1).Table 1Comparison of the flow rate, relative humidity, and temperature of gas supplied by some commercially available HFNOT devicesDevice tradenameFlow rate (litre min−1)Relative humidity (%)Gas temperature (°C)Standard nasal cannula1–4Not humidifiedNot warmedSalter adult high flow cannula 1600HF™15Not humidifiedNot warmedVapotherm precision 2000i high flow therapy™5–4095–10033–43Fisher and Paykel optiflow high flow nasal cannula™1–6010037 Open table in a new tab There are a number of different commercially available HFNOT sets. Some patient interfaces have soft contoured wide-bore nasal prongs designed to reduce gas jetting, while others are used with traditional narrow-bore nasal cannula. Wide-bore cannulae are worn with an adjustable head strap with quick release catch. An attachment for use with tracheostomy tubes is available. The interfaces are intended for single patient use with a maximum duration of use of 30 days. Some devices have a water jacket delivery system surrounding the breathing circuit to provide insulation, while others provide warmed breathable tubing to reduce condensation build up. Inspiratory limb connections are 15 or 22 mm. They are latex-free and have a maximum resistance to flow of 11.6 cm H2O. An aerosol adapter can be attached between the nasal cannulae and delivery tubing circuit to allow administration of nebulized drugs (Figs Fig 1, Fig 2).Fig 2Optiflow brand equipment detail, including humidifier, flow meter, stand, gas supply, and tubing.View Large Image Figure ViewerDownload (PPT) Humidity is provided by a disposable vapour transfer cartridge, a bubble humidifier, or a heated plate humidifier.3Ward JJ High-flow oxygen administration by nasal cannulae for adult and perinatal patients.Respir Care. 2013; 58: 98-122Crossref PubMed Scopus (154) Google Scholar The vapour transfer cartridge is a patented device that surrounds the gas flow. Water diffuses through the cartridge, is heated, and passes into the gas flow as vapour. The bubble humidifier used in high-flow nasal oxygen delivery systems has been designed for use at higher flows than a traditional bubble humidifier. Gas is directed into a water bottle where small bubbles are formed. These gain humidity as they increase to the surface of the water. The heated plate humidifier has a single-use water chamber over which gas flows and is humidified up to 100% relative humidity. In health, quiet breathing generates gas flows in the region of 15 litre min−1 and this air is warmed and humidified in the upper airway. During nose breathing, this occurs through the evaporation of water from the nasal mucosa, with an increased surface area for this provided by the nasal turbinates. Gases reach a temperature of 36°C and humidification of 80–90% during passage through the upper airway. Inhalation of air through the mouth, however, reduces the maximum achievable relative humidity to 70%. During exercise or respiratory distress, flow rates of up to 120 litre min−1 can be reached. This results in increased fluid losses and a higher metabolic oxygen requirement to achieve warmed gases. Flow rates such as this are achievable for only short periods of time and limited by fatigue. The application of cold, dry gases to patients with an increased oxygen requirement may exacerbate the heat loss and is associated with discomfort and reduced compliance with therapy. When this occurs, gas humidification decreases below 50% of relative humidity which can result in drying of secretions, reduced cilial function, and poor mucous flow.4Waugh JB Granger WM An evaluation of 2 new devices for nasal high-flow gas therapy.Respir Care. 2004; 49: 902-906PubMed Google Scholar This may lead to mucus plugging with resultant airway obstruction and arterial oxygen desaturation. Additionally, poor mucus flow predisposes to respiratory tree infection. Table 2 summarizes the physiological benefits of HFNOT.Table 2Summary of the physiological benefits provided by each feature of HFNOT delivery systemsFeature of HFNOTPhysiological effectWarmed humidified gasReduced airway surface dehydrationImproved secretion clearanceDecreased atelectasisGas flow of up to 60 litre min−1CO2 washout, reduction in anatomical dead spaceProvides an oxygen reservoirAllows FIO2 close to 1.0 to be deliveredPEEPIncreased end-expiratory lung volumeAlveolar recruitment Open table in a new tab Humidification and warming devices are available for facemask therapy but not widely used with nasal cannulae therapy. Conversely, HFNOT provides effective humidification and warming of gases, which allows more effective clearance of secretions, decreases atelectasis, and prevents airway surface dehydration.4Waugh JB Granger WM An evaluation of 2 new devices for nasal high-flow gas therapy.Respir Care. 2004; 49: 902-906PubMed Google Scholar It has been demonstrated that patients with acute hypoxaemic respiratory failure experience improved comfort and tolerance with HFNOT compared with humidified oxygen via a facemask, and traditional non-invasive ventilation masks.5Roca O Riera J Torres F Masclans JR High-flow oxygen therapy in acute respiratory failure.Respir Care. 2010; 55: 408-413PubMed Google Scholar Subjective feelings of dyspnoea and respiratory rates are reduced as is airway dryness.6Schwabbauer N Berg B Blumenstock G Haap M Hetzel J Reissen R Nasal high-flow oxygen therapy in patients with hypoxic respiratory failure: effect on functional and subjective respiratory parameters compared to conventional oxygen therapy and non-invasive ventilation (NIV).BMC Anaesthesiol. 2014; 14: 66Crossref PubMed Scopus (103) Google Scholar Sensations of neck discomfort and gas flow being too warm have been rarely reported. This can be avoided by commencing HFNOT at lower flows and gradually increasing the temperature of the inspired gases. In our experience, commencing therapy at 25 litre min−1 and 31°C for the first 15 min improves patient compliance to increasing flows and temperatures. We recommend titrating gas temperature to between 34 and 37°C within the initial 30 min of therapy. This ensures that the important therapeutic benefit of humidified inspiratory gases is conferred early. Optimizing patient comfort is vital in the treatment of respiratory failure, not only to improve patient experience but also reduce rates of failed non-invasive ventilatory support and complications from intubation. Conventional oxygen delivery devices can deliver cold, dry gases at up to 15 litre min−1, thus entrainment of air will limit the fraction of inspired oxygen (FIO2) that is possible to deliver with these devices. HFNOT by virtue of its ability to match higher inspiratory gas flows allows a higher FIO2 delivery of up to 1.0 in moderate respiratory distress. Measured nasopharyngeal FIO2 values correspond closely to the FIO2 set on the device, unless the patient is grossly tachypnoeic.7Ritchie JE Williams AB Gerard C Hockey H Evaluation of a humidified nasal high-flow oxygen system, using oxygraphy, capnography and measurement of upper airway pressures.Anaesth Intensive Care. 2011; 39: 1103-1110Crossref PubMed Google Scholar HFNOT provides an anatomical oxygen reservoir within the nasopharynx and oropharynx, by virtue of a CO2 washout effect due to high oxygen flow. This reduces dead space6Schwabbauer N Berg B Blumenstock G Haap M Hetzel J Reissen R Nasal high-flow oxygen therapy in patients with hypoxic respiratory failure: effect on functional and subjective respiratory parameters compared to conventional oxygen therapy and non-invasive ventilation (NIV).BMC Anaesthesiol. 2014; 14: 66Crossref PubMed Scopus (103) Google Scholar and in turn, work of breathing. There is also a CPAP effect3Ward JJ High-flow oxygen administration by nasal cannulae for adult and perinatal patients.Respir Care. 2013; 58: 98-122Crossref PubMed Scopus (154) Google Scholar which provides an upper airway distending pressure of 3.2–7.4 cm H2O with the mouth closed.8Chanques G Riboulet F Molinari N et al.Comparison of three high flow oxygen therapy delivery devices: a clinical physiological cross-over study.Minerva Anestesiol. 2013; 79: 1344-1355PubMed Google Scholar This results in positive airway pressure, increased end-expiratory lung volume, and thus alveolar recruitment, an effect that may be larger in patients with a higher body mass index. The distending pressure is transmitted to the lower airways to generate PEEP. It is, however, dependent to some extent on closed mouth breathing, and therefore, the PEEP generated is variable. The splinting of the upper airway that occurs due to this also has the effect of reducing airflow resistance in the nasopharynx, thus reducing work of breathing. The initial rationale for the use of HFNOT in neonates was to provide a distending pressure to counteract a lack of surfactant. Its use in neonates is now widespread and is backed by a large evidence base.3Ward JJ High-flow oxygen administration by nasal cannulae for adult and perinatal patients.Respir Care. 2013; 58: 98-122Crossref PubMed Scopus (154) Google Scholar In adults, HFNOT is gaining popularity in the treatment of acute respiratory failure (ARF), in the management of difficult airways, to improve gas exchange post-abdominal and cardiac surgery, in the post-extubation and immediate pre-intubation period in intensive care, and to facilitate bronchoscopy. HFNOT is useful for the treatment of ARF due to its ability to provide an FIO2 of close to 1.0, PEEP of ∼5 cm H2O, and humidified gases through a comfortable interface. The FLORALI trial has shown that HFNOT can reduce intubation requirements in patients with non-cardiogenic ARF with a PaO2/FIO2 ratio of <200 mm Hg. No difference in intubation rate is seen in patients with a higher PaO2/FIO2 ratio. This trial also noted a significantly reduced mortality rate in patients receiving HFNOT, both during intensive care unit (ICU) admission and within 90 days.9Frat JP Ragot S Thille AW High-flow oxygen through nasal cannula in acute hypoxaemic respiratory failure.N Engl J Med. 2015; 372: 2185-2196Crossref PubMed Scopus (1297) Google Scholar HFNOT can be particularly useful in ARF patients with increased work of breathing who do not tolerate facemask therapy or those who have a high secretion load. Much of the work done in this area has a focus on patient comfort and tolerability. A comparison of Venturi facemask oxygen therapy, HFNOT, and non-invasive facemask ventilation (NIV) in patients with ARF due to infection revealed the most improvement in subjective dyspnoea with HFNOT.6Schwabbauer N Berg B Blumenstock G Haap M Hetzel J Reissen R Nasal high-flow oxygen therapy in patients with hypoxic respiratory failure: effect on functional and subjective respiratory parameters compared to conventional oxygen therapy and non-invasive ventilation (NIV).BMC Anaesthesiol. 2014; 14: 66Crossref PubMed Scopus (103) Google Scholar The greatest increase in arterial oxygen tension was seen with NIV, but this had the lowest patient acceptance score. Other studies corroborate these findings.10Sztrymf B Messika J Mayot T Lenglet H Dreyfuss D Ricard JD Impact of high-flow nasal cannula oxygen therapy on intensive care unit patients with acute respiratory failure: a prospective observational study.J Crit Care. 2012; 27: 324,e9-324,13Abstract Full Text Full Text PDF PubMed Scopus (211) Google Scholar HFNOT has also been used in patients with hypoxaemia due to cardiogenic pulmonary oedema, where the application of PEEP resulting from HFNOT led to improved dyspnoea and arterial oxygen tension.3Ward JJ High-flow oxygen administration by nasal cannulae for adult and perinatal patients.Respir Care. 2013; 58: 98-122Crossref PubMed Scopus (154) Google Scholar Its use in chronic obstructive pulmonary disease (COPD) patients requires further evaluation, particularly in the setting of acute exacerbations. It has been shown, however, that high-flow nasal cannulae oxygen therapy reduces respiratory rate and increases minute volume in COPD patients both at rest and during exercise.11Rea H McAuley S Jayaram L et al.The clinical utility of long-term humidification therapy in chronic airway disease.Resp Med. 2010; 104: 525-533Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar Patient selection is an important factor in the success of HFNOT therapy. As with NIV, delay in initiating invasive ventilation via tracheal intubation caused by inappropriate perseverance with HFNOT may result in increased ICU mortality and worsened outcomes. There is a place for HFNOT in emergency and elective airway management. Preoxygenation, to denitrogenate the lungs, provides an oxygen reservoir for use during apnoea. This is a core principle in airway management, not just in the anticipated difficult airway. Increasing the viable apnoeic window is highly desirable in the management of the difficult airway, and in those patients with a reduced functional residual capacity, or increased metabolic demand for oxygen. These patients will have a limited oxygen reservoir, and reduced time to desaturation. Obstetric, bariatric, and septic patients represent potential groups where preoxygenation with HFNOT may be beneficial. It has been used successfully in awake fibreoptic intubation, where a major advantage appears to be its ability to provide an FIO2 of nearing 1.0 via soft nasal cannulae that allow the passage of a fibreoptic scope.12Badiger S John M Fearnley RA Ahmad I Optimising oxygenation and intubation conditions during awake fibre-optic intubation using a high-flow nasal oxygen-delivery system.Br J Anaesth. 2015; 115: 629-632Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar Insufflation of oxygen into the lungs during apnoea can maintain oxygenation through diffusion. This effect is well described and is likely one of a number of mechanisms by which jet ventilation oxygenates the lungs. Recent attention has focused on the use of HFNOT in the difficult airway and its ability to increase the time to desaturation, and decrease the severity of the desaturation in anaesthetized patients, allowing for unhurried attempts at intubation.13Patel A Nouraei SAR Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE): a physiological method of increasing apnoea time in patients with difficult airways.Anaesthesia. 2015; 70: 323-329Crossref PubMed Scopus (421) Google Scholar This effect extends to the critical care population requiring intubation, where fewer and less severe episodes of arterial desaturation are seen when preoxygenated with HFNOT, rather than high-flow oxygen using a conventional facemask.14Miguel-Montanes R Hajage D Messika J et al.Use of high-flow nasal cannula oxygen therapy to prevent desaturation during tracheal intubation of intensive care patients with mild-to-moderate hypoxemia.Crit Care Med. 2015; 43: 574-583Crossref PubMed Scopus (217) Google Scholar This effect is not seen in all populations, notably those with severe respiratory failure.15Vourc'h M Asfar P Volteau C et al.High-flow nasal cannula oxygen during endotracheal intubation in hypoxaemic patients: a randomized controlled clinical trial.Intensive Care Med. 2015; 41: 1538-1548Crossref PubMed Scopus (184) Google Scholar Carbon dioxide (CO2) is cleared to some extent in apnoeic application of HFNOT possibly due to diffusion after washout of CO2 from the anatomical dead space. However, it is important to remember that periods of apnoea in excess of 15 min can be achieved with HFNOT, but arterial CO2 levels may increase to dangerous levels, resulting in severe acidosis. Postoperative hypoxaemia is common in patients undergoing major abdominal surgery, due to derecruitment of lung alveoli, atelectasis, and altered respiratory mechanics secondary to pain. Increasing the FIO2, although useful in treating the arterial hypoxaemia, will not treat the cause of the problem. The application of CPAP after elective abdominal surgery can reduce the need for tracheal intubation, and the development of postoperative chest infections in hypoxaemic patients.16Squadrone V Coha M Cerutti E et al.Continuous positive airway pressure for treatment of postoperative hypoxemia: a randomized controlled trial.J Am Med Assoc. 2005; 293: 589-595Crossref PubMed Scopus (507) Google Scholar The ‘Optiflow for prevention of post-extubation hypoxemia after abdominal surgery’ (OPERA) trial will assess postoperative hypoxaemia, pulmonary complications, and the need for NIV or tracheal intubation after abdominal surgery in patients receiving early HFNOT.17Futier E Paugam-Burtz C Constantin JM Pereira B Jaber S The OPERA trial—comparison of early nasal high flow oxygen therapy with standard care for prevention of postoperative hypoxaemia after abdominal surgery: study protocol for a multicenter randomized controlled trial.Trials. 2013; 14: 341-348Crossref PubMed Scopus (30) Google Scholar If this therapy is shown to reduce postoperative pulmonary complications then more widespread application of HFNOT, particularly in ward-based settings, may be beneficial. The use of HFNOT has been assessed in the post-cardiac surgery population, where it was shown to reduce respiratory rate, and increase end-expiratory lung volume. It can reduce the requirement for CPAP via a facemask interface and re-intubation rates but has not been consistently shown to improve other respiratory parameters such as SpO2/FIO2 ratios or basal atelectasis.18Corley A Caruana LR Barnett AG Tronstad O Fraser JF Oxygen delivery though high-flow nasal cannulae increase end-expiratory lung volume and reduce respiratory rate in post-cardiac surgical patients.Br J Anaesth. 2011; 107: 998-1004Crossref PubMed Scopus (353) Google Scholar There are some reports that a larger effect is seen in the obese population, but a recent study into this group of patients post-cardiac surgery failed to show any improvement in respiratory parameters between HFNOT and conventional oxygen therapy. Rates of re-intubation, however, were significantly reduced. It has been shown that HFNOT is not inferior in preventing re-intubation compared with NIV in this population.19Stephan F Barrucand B Petit P et al.High-flow nasal oxygen vs noninvasive positive airway pressure in hypoxemia patients after cardiothoracic surgery. A randomised clinical trial.J Am Med Assoc. 2015; 313: 2331-2339Crossref PubMed Scopus (375) Google Scholar This study compared 24 h of HFNOT with 6 h of therapy with bilevel positive airways pressure. A comparison with CPAP in the postoperative period would also be of use. There is a growing movement towards HFNOT use in patients undergoing bronchoscopy. It could be a useful tool in patients with mild hypoxaemia undergoing bronchoscopy. Patients undergoing bronchoscopy in a critical care setting are relatively hypoxaemic. Bronchoscopy increases V/Q mismatch, and may result in basal lung collapse due to suctioning of airways. Application of end-expiratory pressure during the procedure would be a logical counter to these effects, but choice of the appropriate method to achieve this should be patient-specific. HFNOT is a comparatively well tolerated and comfortable method of respiratory support. In our centre like many other hospitals, it is used in selected ward environments. The support of a critical care outreach team is recommended to prevent unnoticed deterioration and the potential for delay in commencing mechanical ventilation if required. HFNOT could be suitable for use in some patients deemed not suitable for intubation, or patients requiring palliative care. It reduces respiratory rate in respiratory failure and can alleviate respiratory distress symptoms in cancer patients.20Peters SG Holets SR Gay PC Nasal high flow oxygen therapy in do-not-intubate patients with hypoxaemic respiratory distress.Respir Care. 2013; 58: 597-600PubMed Google Scholar It has also been assessed as a long-term home therapy in COPD patients. It does not reduce frequency of exacerbations of COPD, but may reduce the duration of these events.11Rea H McAuley S Jayaram L et al.The clinical utility of long-term humidification therapy in chronic airway disease.Resp Med. 2010; 104: 525-533Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar Contraindications to the use of HFNOT are much the same as for NIV delivered via a facemask or hood. HFNOT should not delay mechanical ventilation in those with severe respiratory failure, particularly in type II respiratory failure. Any contraindication to the application of PEEP should prompt alternative methods of respiratory support to be sought. Additionally, it should not be used on those with reduced levels of consciousness, or uncooperative patients. In addition, epistaxis, facial injury, or airway obstruction should preclude its use. The applications for HFNOT are already extending beyond its use in critical care. In some centres, it is used hospital-wide and may become a replacement for conventional nasal cannula, allowing administration of warmed humidified oxygen to those not necessarily requiring high-flow gas. We anticipate that it may be of use in prehospital care and inter-hospital transfers, primarily for its ability to deliver an FIO2 of close to 1.0. Alongside the clinical advantages, HFNOT offers practical benefits such as improved patient compliance and the ability to eat, drink, and communicate while receiving therapy. In our experience, these have a significant impact on patient morale. We anticipate growth in the use and acceptance of HFNOT and envisage that high flow, cold dry gases administered via a facemask may become a relic of the past. The triad of humidity, compliance, and high FIO2 that HFNOT offers is likely to be of use in a wide variety of clinical situations. There are various devices available for use, which deliver varying maximum flow rates and humidification. This is a rapidly evolving area and the evidence for its use in acute hypoxaemic respiratory failure, advanced airway management, and the postoperative population is growing. None declared. The associated MCQs (to support CME/CPD activity) can be accessed at https://access.oxfordjournals.org by subscribers to BJA Education." @default.
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