High-Flow Nasal Oxygen in Hospitalized Patients With Respiratory Failure

May 07, 2021
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Authors:
Qaseem A, Etxeandia-Ikobalzeta I, Fitterman N, Williams JW Jr, Kansagara D, on behalf of the Clinical Guidelines Committee of the American College of Physicians.
Citation:
Appropriate Use of High-Flow Nasal Oxygen in Hospitalized Patients for Initial or Postextubation Management of Acute Respiratory Failure: A Clinical Guideline From the American College of Physicians. Ann Intern Med 2021;Apr 27:[Epub ahead of print].
Summary By:
Rachel Eshima McKay, MD

Quick Takes

  • High-flow nasal oxygen (HFNO) offers physiologically favorable features to patients with acute hypoxemic ventilatory failure; its impact on a broad range of clinical outcomes is explored in this guideline document.
  • Compared to use of noninvasive ventilation, HFNO during initial presentation was associated with a large reduction in all-cause mortality, and modest decrease in risk of intubation. Compared to conventional oxygen delivery, HFNO after extubation may reduce the risk of reintubation.
  • For patients with respiratory failure, the ACP Guidelines recommend: 1) HFNO versus noninvasive ventilation during initial support, and 2) HFNO versus conventional oxygen treatment after extubation.

Study Questions:

High-flow nasal oxygen (HFNO) delivers humidified oxygen at rates that exceed physiologic inspiratory flow. Physiologic benefits of HFNO include improvements in oxygenation and lung compliance versus conventional oxygen therapy (COT), and HFNO may obviate hemodynamic and aspiration risks, and afford greater comfort compared to use of noninvasive ventilation (NIV). What is the published evidence supporting use of HFNO in hospitalized patients with primary or post-extubation respiratory failure, as examined in the American College of Physicians (ACP) guideline document?

Methods:

The ACP guideline committee searched Medline, EMBASE, Cochrane, and CINAHL for randomized controlled trials and systematic reviews, published between January 2000 and July 2020, investigating patient-centered clinical outcomes among hospitalized patients with respiratory failure who received HFNO versus NIV (i.e., continuous or bilevel positive pressure support) or COT for support during initial and post-extubation phases of management.

Results:

For the initial management of hypoxic respiratory failure:

Low-certainty evidence showed that HFNO versus NIV was associated with the following statistically significant outcome differences (absolute risk difference [95% confidence interval]):

  • Large reduction in all-cause mortality (-15.8 [-21.4, -5.9]%);
  • Modest reduction in subsequent need for intubation (-9.4 [-15.2, -1.6]%).

Low-certainty evidence showed that HFNO versus NIV was associated with possible (statistically nonsignificant [NS]) reduction in hospital-acquired pneumonia (-4.4 [-7.0, 3.7])%.

Low-certainty evidence showed that use of HFNO versus COT was associated with:

  • Possible (statistically NS) modest reduction in hospital-acquired pneumonia (-4.7 [-7.3, 3.7]%);
  • No apparent difference in all-cause mortality (-0.8 [-4.9, 3.8]%);
  • No apparent difference in subsequent need for intubation (-0.4 [-15.6, 23.9]%).

For the management of post-extubation respiratory failure, low-certainty evidence showed that HFNO versus NIV was associated with the following outcome differences:

  • Possible (statistically NS) large reduction in skin breakdown (-19.7 [-23.7, 2.3]%);
  • Possible (statistically NS) increase in reintubation (2.0 [-1.5, 6.6]%);
  • Possible (statistically NS) increase in mortality (1.7 [-1.3, 5.7]%).

For the management of post-extubation respiratory failure, low-certainty evidence showed that HFNO versus COT was associated with the following outcome differences:

  • Possible (statistically NS) reduction in reintubation (-3.9 [-7.8, 5.3]%);
  • No apparent difference in pneumonia (-1.1 [-2.0, 2.2]%);
  • No apparent difference in mortality (0.1 [-2.5, 4.0]%).

Conclusions:

For treatment of patients with hypoxic and hypercapneic respiratory failure, the ACP guideline committee recommends: 1) use of HFNO versus NIV for initial support, and 2) use of HFNO versus COT for post-extubation support. These are both conditional, low-certainty recommendations based on available evidence.

Perspective:

HFNO showed significant advantages of lower mortality and need for intubation compared to NIV in hospitalized patients during initial presentation of respiratory failure. Data on impact in distinct clinical subpopulations will be important going forward to determine its role.

Clinical Topics: Prevention, Sleep Apnea

Keywords: Airway Extubation, Biometry, Hemodynamics, Hypoventilation, Intubation, Intratracheal, Lung Compliance, Noninvasive Ventilation, Oxygen Inhalation Therapy, Patient-Centered Care, Pneumonia, Primary Prevention, Respiratory Distress Syndrome, Respiratory Insufficiency


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