While O2 therapy via HFNC was in use prior to the pandemic, it had been limited to very specific situations, such as the treatment of hypoxemia, asthma and bronchiolitis in infants and pediatric patients.

Now that use of HFNC has been widely used to treat COVID-19 patients, we are experiencing an expansion of therapeutic indications for this oxygen delivery modality.

In April 2021, the American College of Physicians (ACP) released a new Clinical Guideline with recommendations for the appropriate use of oxygen therapy via HFNC in hospitalized patients, citing the benefits of HFNC compared to conventional oxygen therapy (COT) and high-flow systems and noninvasive ventilation (NIV).

The ACP noted, “The purported benefits of [HFNC] compared to conventional oxygen therapy (COT) and high-flow systems and noninvasive ventilation (NIV) include improved patient comfort, compliance and physiological advantages,” adding how the therapy can be used “as respiratory support in critically ill patients for a number of indications, including respiratory failure or support post-extubation.”ⁱⁱⁱ

 Here are four reasons why clinicians should rethink the use of HFNC in a broader population of patients moving forward.

Endotracheal intubation has been common practice when treating respiratory distress, but it comes with a variety of potential risks, including airway damage and infection.^iv,v,vi

On the other hand, oxygen therapy delivered via HFNC is non-invasive and has been shown to reduce the rate of intubation, mechanical ventilation and the escalation of respiratory support in various groups of patients, ^{vii, viii,ix,x}. It can also reduce the risk for reintubation among extubated patients.^xi

Endotracheal intubation has historically been the first line of support for respiratory failure, but patients often suffer distress and discomfort while the tube is in place. For example, in one study, the majorty of patients who were intubated and on mechanical ventilation reported feeling afraid because they could not communicate verbally^xii, whereas HFNC facilitates normal speech.

HFNC administered via nasal cannula is non-invasive compared to intubation, making it a more convenient and comfortable option. Furthermore, studies show that high-flow therapy administered via nasal cannula is typically more comfortable for patients compared with noninvasive ventilation (NIV) via face mask.^xiii

Immediately intubating a patient in respiratory distress is not always necessary and can increase the risk for complications. One study found more than one third of intubations in patients transferred to burn centers were unnecessary, exposing patients to unwarranted complications.^xiv

By starting oxygen therapy with a HFNC and monitoring the patient’s respiratory status, clinicians may delay or avoid intubation.^xv If a patient’s status is stabilized while on HFNC, clinicians can continue with this therapy, potentially decreasing complications, ICU days and cost to the hospital.^xvi

One article noted that despite certain issues, “a growing body of evidence suggests that HFNC oxygen therapy is an innovative and effective modality for the early treatment of adults with respiratory failure associated with diverse underlying diseases.”^xvii It allows for clinicians to administer additional therapies in conjunction with oxygen to treat a variety of conditions. 

For example, HFNC can be administered alongside nitric oxide therapy for patients suffering from pulmonary hypertension. In fact, researchers believe the addition of high flow oxygen may drastically decrease the inhaled nitric oxide (iNO2) requirement in the treatment of pulmonary hypertension.^xviii

Out of the devastation of the COVID-19 pandemic has come many lessons learned and best practices to carry healthcare delivery forward. The benefits of oxygen therapy via HFNC over endotracheal intubation in cases where this non-invasive therapy is appropriate were observed on certain SARS-CoV-2 patients at the University of Chicago Medicine and have since been extended to other care areas. Perhaps expanded use of HFNC will continue in the years ahead, offering clinicians a less traumatic and less risky intervention for patients in respiratory distress.

While HFNC has proven successful in many patients, others will still require intubation and mechanical ventilation. Still others may fare better with NIV via face mask.

When an organization is considering the purchase of ventilators, it should also consider the modes of therapy delivered, as well as the vendor’s ability to support those modes with high quality consumables. That way, clinicians can switch a patient between traditional ventilation mode to HFNC or non-invasive mask to meet changing needs all while still using the same machine. This approach also supports successful transition of patients down on oxygen therapy to wean them/move them out of the ICU.

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^{[i] https://news.uchicago.edu/story/uchicago-doctors-see-remarkable-success-using-ventilator-alternatives-covid-19}

^{[ii] https://news.uchicago.edu/story/uchicago-doctors-see-remarkable-success-using-ventilator-alternatives-covid-19}

^{[iii] New recommendations for high-flow nasal oxygen in hospitalized patients with acute respiratory failure, American College of Physicians (ACP), April 27, 2021, https://medicalxpress.com/news/2021-04-high-flow-nasal-oxygen-hospitalized-patients.html}

^{[iv] Tikka T, Hilmi OJ. Upper airway tract complications of endotracheal intubation. Br J Hosp Med (Lond). 2019 Aug 2;80(8):441-447. doi: 10.12968/hmed.2019.80.8.441. PMID: 31437047. https://pubmed.ncbi.nlm.nih.gov/31437047/}

^{[v] Thorarinsdottir HR, Kander T, Holmberg A, Petronis S, Klarin B. Biofilm formation on three different endotracheal tubes: a prospective clinical trial. Crit Care. 2020 Jun 29;24(1):382. doi: 10.1186/s13054-020-03092-1. PMID: 32600373; PMCID: PMC7322705. https://pubmed.ncbi.nlm.nih.gov/32600373/}

^{[vi] Ni YN, Luo J, Yu H, Liu D, Liang BM, Liang ZA. The effect of high-flow nasal cannula in reducing the mortality and the rate of endotracheal intubation when used before mechanical ventilation compared with conventional oxygen therapy and noninvasive positive pressure ventilation. A systematic review and meta-analysis. Am J Emerg Med. 2018 Feb;36(2):226-233. doi: 10.1016/j.ajem.2017.07.083. Epub 2017 Jul 28. PMID: 28780231. https://pubmed.ncbi.nlm.nih.gov/28780231/}

^{[vii] https://journals.sagepub.com/doi/full/10.1177/1753466620956459}

^{[viii] Zhao H, Wang H, Sun F, Lyu S, An Y. High-flow nasal cannula oxygen therapy is superior to conventional oxygen therapy but not to noninvasive mechanical ventilation on intubation rate: a systematic review and meta-analysis. Crit Care. 2017 Jul 12;21(1):184. doi: 10.1186/s13054-017-1760-8. PMID: 28701227; PMCID: PMC5508784. https://pubmed.ncbi.nlm.nih.gov/28701227/}

^{[ix] Zhao H, Wang H, Sun F, Lyu S, An Y. High-flow nasal cannula oxygen therapy is superior to conventional oxygen therapy but not to noninvasive mechanical ventilation on intubation rate: a systematic review and meta-analysis. Crit Care. 2017 Jul 12;21(1):184. doi: 10.1186/s13054-017-1760-8. PMID: 28701227; PMCID: PMC5508784. https://pubmed.ncbi.nlm.nih.gov/28701227/}

^{[x] Nishimura, M. High-flow nasal cannula oxygen therapy in adults. j intensive care 3, 15 (2015). https://doi.org/10.1186/s40560-015-0084-5 https://jintensivecare.biomedcentral.com/articles/10.1186/s40560-015-0084-5#citeas}

^{[xi] Hernández G, Vaquero C, González P, Subira C, Frutos-Vivar F, Rialp G, Laborda C, Colinas L, Cuena R, Fernández R. Effect of Postextubation High-Flow Nasal Cannula vs Conventional Oxygen Therapy on Reintubation in Low-Risk Patients: A Randomized Clinical Trial. JAMA. 2016 Apr 5;315(13):1354-61. doi: 10.1001/jama.2016.2711. PMID: 26975498. https://pubmed.ncbi.nlm.nih.gov/26975498}

^{[xii] Roberts, Melanie DNP, RN-BC, CNS, CCNS, CCRN; Bortolotto, Shannon Johnson MS, RN, APRN, CCNS; Weyant, Ruth A. MSN, RN, CCRN-CMC; Jock, Leighann MSN, RN, CCNS; LaLonde, Trent PhD; Henderson, Ann PhD, APRN, CNS The Experience of Acute Mechanical Ventilation From the Patient's Perspective, Dimensions of Critical Care Nursing: 7/8 2019 - Volume 38 - Issue 4 - p 201-212 doi: 10.1097/DCC.0000000000000361 https://journals.lww.com/dccnjournal/Abstract/2019/07000/The_Experience_of_Acute_Mechanical_Ventilation.6.aspx}

^{[xiii] High-flow nasal oxygen therapy and noninvasive ventilation in the management of acute hypoxemic failure Frat JP, Coudroy R, Marjanovic N, Thille AW: Ann Transl Med. Jul;5(14):297}

^{[xiv] Romanowski KS, Palmieri TL, Sen S, Greenhalgh DG. More Than One Third of Intubations in Patients Transferred to Burn Centers are Unnecessary: Proposed Guidelines for Appropriate Intubation of the Burn Patient. J Burn Care Res. 2016 Sep-Oct;37(5):e409-14. doi: 10.1097/BCR.0000000000000288. PMID: 26284640. https://pubmed.ncbi.nlm.nih.gov/26284640/}

^{[xv] Noninvasive Ventilation and High-Flow Nasal Cannula Might Help Avoid Intubation for Hypoxemic Respiratory Failure, June 23, 2020, https://www.jwatch.org/na51775/2020/06/23/noninvasive-ventilation-and-high-flow-nasal-cannula-might}

^{[xvi] Wittenstein J, Ball L, Pelosi P, Gama de Abreu M. High-flow nasal cannula oxygen therapy in patients undergoing thoracic surgery: current evidence and practice. Curr Opin Anaesthesiol. 2019 Feb;32(1):44-49. doi: 10.1097/ACO.0000000000000682. PMID: 30543553. https://pubmed.ncbi.nlm.nih.gov/30543553/}

^{[xvii] Nishimura, M. High-flow nasal cannula oxygen therapy in adults. j intensive care 3, 15 (2015). https://doi.org/10.1186/s40560-015-0084-5 https://jintensivecare.biomedcentral.com/articles/10.1186/s40560-015-0084-5#citeas}

^{[xviii] Huang J., Fridman D, High Flow Oxygen and Low Dose Inhaled Nitric Oxide in a Case of Severe Pulmonary Hypertension and Obstructive Shock, Chest. 2011;140(4_MeetingAbstracts):63A. doi:10.1378/chest.1117113 https://journal.chestnet.org/article/S0012-3692(16)53816-1/pdf}