ERS clinical practice guidelines: high-flow nasal cannula in acute respiratory failure

Abstract

BackgroundHigh-flow nasal cannula (HFNC) has become a frequently used non-invasive form of respiratory support in acute settings, however evidence supporting its use has only recently emerged. These guidelines provide evidence-based recommendations for the use of HFNC alongside other noninvasive forms of respiratory support in adults with acute respiratory failure (ARF).Materials and methodologyThe European Respiratory Society Task Force panel included expert clinicians and methodologists in pulmonology and intensive care medicine. The Task Force used the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) methods to summarise evidence and develop clinical recommendations for the use of HFNC alongside conventional oxygen therapy (COT) and non-invasive ventilation (NIV) for the management of adults in acute settings with ARF.ResultsThe Task Force developed 8 conditional recommendations, suggesting using: 1) HFNC over COT in hypoxemic ARF, 2) HFNC over NIV in hypoxemic 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 non-surgical 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 chronic obstructive pulmonary disease (COPD) and hypercapnic ARF.ConclusionsHFNC is a valuable intervention in adults with ARF. These conditional recommendations can assist clinicians in choosing the most appropriate form of non-invasive respiratory support to provide to patients in different acute settings.

Current Practice of High Flow through Nasal Cannula in Exacerbated COPD Patients

“…The evidence supporting the use of HFNC is increasing in patients with hypoxemic ARF or after extubation, whereas data on AECOPD are still weak [ 55 ]. The recent guidelines suggest a trial of NIV prior to the use of HFNC in the case of AECOPD with respiratory acidosis [ 55 ].…”

“…The evidence supporting the use of HFNC is increasing in patients with hypoxemic ARF or after extubation, whereas data on AECOPD are still weak [ 55 ]. The recent guidelines suggest a trial of NIV prior to the use of HFNC in the case of AECOPD with respiratory acidosis [ 55 ]. Indeed, the literature recommends the application of NIV in AECOPD patients with respiratory acidosis [ 2 ], whereas the certainty of the evidence for mortality and intubation in favor of HFNC is low, mainly due to imprecision and heterogeneity among trials [ 55 ].…”

“…In addition, the temperature of the gas flow should be set between 34 and 37 °C, according to the patient’s tolerance. In the end, the FiO 2 should be adjusted in order to obtain a SpO 2 between 88 and 92% [ 55 ].…”

“…The recent European Respiratory Society Guidelines still suggest firstly attempting NIV in AECOPD patients since the existing evidence is large and strong; however, if NIV fails due to poor tolerance and gas exchange are not worsening, HFNC may be attempted [ 55 ].…”

Management of COVID-19-Associated Acute Respiratory Failure with Alternatives to Invasive Mechanical Ventilation: High-Flow Oxygen, Continuous Positive Airway Pressure, and Noninvasive Ventilation

“…HFNC involves the delivery of a high flow of warm humidified oxygen (up to 60 L/min) through a small nasal cannula, improving oxygenation and reducing respiratory rates, as well as providing higher concentrations of oxygen than therapy with supplemental oxygen alone [ 76 , 77 ]. In patients who did not have COVID-19, the European Respiratory Society (ERS) recommends HFNC therapy to patients with hypoxic respiratory failure over conventional nasal cannula therapy and NIV; however, they do not recommend HFNC over NIV in patients at high risk of extubation failure, in patients with chronic obstructive pulmonary disease (COPD), or in patients with hypercapnic ARF [ 78 ]. Treatment with HFNC resulted in similar mortality rates but less frequent intubation, compared to patients treated with conventional oxygen therapy [ 79 ], and HFNC is usually tolerated quite well [ 80 ].…”