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There are many beneficial mechanisms of action that have been attributed to the effectiveness of high-flow nasal cannula in adult and pediatric patients with respiratory failure. It is not clear which of the benefits are most important, and it may depend on the individual patient's etiology of respiratory failure. The mechanisms of action below are not listed in the order of importance but rather to give the reader an easy to remember mnemonic (HIFLOW) for the mechanisms that have been attributed to the use of high-flow nasal oxygen.
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Heated and humidified oxygen has a number of benefits compared to standard oxygen therapy. Standard oxygen therapy delivered through a nasal cannula or another device, such as a non-rebreather mask (NRBM), delivers cold (not warmed) and dry (not humidified) gas. This cold, dry gas can lead to airway inflammation, increase airway resistance, and impair mucociliary function, possibly impairing secretion clearance [1]. Also, a significant amount of energy is expended by individuals to both warm and humidify gas during normal breathing [2]. Thus, heated and humidified oxygen may improve secretion clearance, decrease airway inflammation, and also decrease energy expenditure, particularly in the setting of acute respiratory failure [1-2].
One obvious benefit is that the high-flow nasal cannula can deliver very high flow rates of gas in an attempt to match a patient's inspiratory flow demands. This is important as patients in acute respiratory failure can become extremely tachypneic, and their peak inspiratory flows (PIF), which may normally be 30 L/min - 60 L/min at rest, can reach upwards of 120 L/min in acute respiratory failure [3]. If these patients with respiratory failure (with PIF rates of up to 60 - 120 L/min and high minute volumes (> 20 L/min in some adults)) are placed on a 15 L/min NRB mask, then this may not provide adequate support. This will be discussed later in this review when we discuss the concept of oxygen dilution. One of the main mechanisms to improve a patient's work of breathing is to attempt to match their peak inspiratory flow demands with the use of a high-flow device.
High-flow nasal cannula use seems to cause alveolar recruitment and increased FRC, as well as increased intrathoracic pressure, likely as a result of the added PEEP; however, it is not certain if perhaps another mechanism may be responsible for these findings.
The majority of the benefits of the high-flow nasal cannula, as we have discussed above, come as a result of the high flow rates that can be delivered (Figure 4). Delivering heated and humidified oxygen has significant benefits, but to optimize the effectiveness of high-flow nasal cannula for the patient, ensure that the inspiratory flow is optimized. As we will discuss in our next section, pediatric data (particularly in bronchiolitis) shows that flow rates of 2 L/kg/min are effective and well tolerated up to maximum flow rates of 60 L/kg/min in adults.
Community-acquired pneumonia would seem like an ideal indication for the use of the high-flow nasal cannula. The heated, humidified oxygen should allow improved mobilization of secretions, and its ability to minimize oxygen dilution, meet inspiratory demands, and improve end-expiratory lung volumes all seem ideal in patients with pneumonia. HFNC may allow patients to cough, mobilize secretions, and be suctioned, if necessary, all benefits that are often difficult to achieve when a patient is on noninvasive positive pressure ventilation (NIPPV). The only exception would be in patients with acute chronic obstructive pulmonary disease (COPD) exacerbations from pneumonia, as there is evidence demonstrating a decreased mortality and need for intubation with the use of NIPPV [9}.
A recent study by Azoulay et al. comparing the use of the high-flow nasal cannula to standard oxygen therapy in immunocompromised patients with acute hypoxemic respiratory failure failed to show a difference in 28-day mortality between the groups [12}. Despite improvements in oxygenation (higher Pa02/Fi02 ratio compared to standard oxygen therapy), high flow nasal cannula also failed to demonstrate a difference in rates of intubation, intensive care unit (ICU) length of stay, ICU-acquired infections, hospital length of stay or patient comfort and dyspnea scores.
Another unique use for high-flow nasal cannula is in patients after extubation who are at low-risk for needing reintubation (Table 2). Hernandez et al. performed a randomized control trial in 527 patients at low-risk for needing reintubation within 72 hours from extubation [13]. Patients were extubated and then randomized to either standard oxygen therapy, which would be considered the standard of care in this group of low-risk patients, or to HFNC. The group extubated to the high-flow nasal cannula had a statistically significant lower rate of reintubation (4.9%) compared to standard oxygen therapy (12.2%). It is unclear why this benefit was seen, but this is certainly a group where many intensivists would not probably attempt the use of high-flow nasal cannula as a therapy as it is usually reserved for more high-risk patients.
Intubation of a critically ill patient is a high-risk procedure with high rates of complications, including hypoxemia, hypotension, and even cardiac arrest [14]. The high-flow nasal cannula device has an advantage compared to alternative methods, such as bag-mask ventilation (BMV) and NIPPV. The high-flow nasal cannula device can stay on the patient and provide continued oxygen therapy, as well as possibly provide positive pressure, even during the apneic period compared to BMV and NIPPV, which have to be removed during the intubation procedure. A high-flow nasal cannula may be as effective as NIPPV and superior to standard oxygen therapy for pre-oxygenation prior to intubation in critical patients [14-16].
The majority of pediatric data supporting the use of high-flow nasal cannula outside of neonatal use is in bronchiolitis. Pediatric patients with mild to severe bronchiolitis have the most evidence to support its use. Franklin et al. conducted a multi-centered, randomized controlled trial comparing the use of high-flow nasal cannula (dose = 2 liters per kilogram/min) to standard oxygen in 1,472 infants (
The majority of the benefits, besides heating and humidification, come from the optimal flow. The mnemonic (HIFLOW) will help one to remember the mechanisms of action, including Heated and humidified, meets Inspiratory demands, increases Functional residual capacity (FRC), Lighter, minimizes Oxygen dilution, and Washout of pharyngeal dead space. The most important mechanism may depend on the individual patient's need for the high-flow nasal cannula.
Principle setup of high-flow nasal cannula oxygen therapy. An air/oxygen blender, allowing from 0.21 to 1.0 FIO2, generates up to 60 L/min flow. The gas is heated and humidified through an active heated humidifier and delivered via a single-limb heated inspiratory circuit. The patient breathes the adequately heated and humidified medical gas through nasal cannulas with a large diameter.
Administration of supplemental oxygen has been the first-line therapy for hypoxemic patients. Oxygen is generally provided via face masks and nasal cannula. Several drawbacks are associated with these devices, which may limit efficacy and tolerance of oxygen delivery. Usually, oxygen is not humidified at low flow, and complaints, especially dry nose, dry throat, and nasal pain, are common. Bubble humidifiers are commonly used for humidifying air delivered to spontaneously breathing patients, but when absolute humidity is low, patients still complain of discomfort [2,3]. Insufficient heating and humidification leads to poor tolerance to oxygen therapy. Using conventional devices, oxygen flow is limited to no more than 15 L/min. Meanwhile, the inspiratory flow of patients with respiratory failure varies widely in a range from 30 to more than 100 L/min. The difference between patient inspiratory flow and delivered flow is large, and as a result, FIO2 is both inconstant and often lower than expected. As an alternative to conventional oxygen delivery for hypoxemic patients, HFNC oxygen therapy has been receiving more and more attention.
For patients with hypoxemic respiratory failure, how well does HFNC work in maintaining stable FIO2 and positive pharyngeal pressure? From the reported physiological effects of HFNC, high flow through a nasal cannula meets resistance from patient expiration, and pressure in the pharynx increases. Since the cannula is part of an open system, pharyngeal pressure may not be high enough comparing to NIV or invasive mechanical ventilation [14,15].
The Philips Respironics SimplyGo Mini is available for purchase from local medical equipment suppliers such as the OxygenConcentratorStore. You can either shop online or at their retail location in Denver.
Portable oxygen concentrators cost between $4,000 and $4,500 from the manufacturer, although you can often find them in the range of $2,500 to $4,000 from online retailers such as the Oxygen Concentrator Store and others. Used portable oxygen concentrators are even less expensive, at a cost of $800 to $2,000. 041b061a72