From the Guidelines
High flow nasal cannula (HFNC) is preferred over BiPAP in pneumonia due to its ability to provide better patient comfort and adequate respiratory support, as evidenced by the most recent and highest quality study 1. The advantages of HFNC over BiPAP in treating pneumonia include:
- Improved patient comfort due to the delivery of heated, humidified oxygen at flow rates up to 60 L/min through nasal prongs, allowing patients to eat, drink, and communicate more easily than with a BiPAP mask.
- Effective secretion clearance due to the humidification, which prevents mucus plugging and aids in expectoration.
- Creation of a mild positive pressure effect (2-5 cmH2O) that helps recruit alveoli without the higher pressures of BiPAP that might cause barotrauma or volutrauma in inflamed lung tissue.
- Reduction of work of breathing by washing out anatomical dead space in the nasopharynx and providing a reservoir of fresh oxygen. For implementation, start with flow rates of 30-40 L/min and FiO2 of 40-60%, titrating based on oxygen saturation goals (typically >92% in most adults), as recommended by the American College of Physicians 1. The system should be properly humidified and heated to 37°C for optimal comfort and secretion management. However, if a patient shows signs of progressive respiratory failure despite HFNC (increased work of breathing, deteriorating blood gases), escalation to BiPAP or intubation should not be delayed, as suggested by the European Respiratory Society task force panel 1.
From the Research
Advantages of High Flow Nasal Cannula (HFNC) over Bi-level Positive Airway Pressure (BiPAP)
- HFNC may lead to less treatment failure as indicated by escalation to alternative types of oxygen therapy compared to standard oxygen therapy 2
- HFNC probably makes little or no difference in mortality when compared with standard oxygen therapy 2
- HFNC may result in little or no difference to cases of pneumonia compared to standard oxygen therapy 2
- HFNC may lead to less treatment failure when compared to standard oxygen therapy, but probably makes little or no difference to treatment failure when compared to NIV or NIPPV, which includes BiPAP 2
- HFNC is well tolerated and easy to use in all clinical settings, reducing the need for more invasive supports 3
- HFNC effectively reduces dyspnoea and improves oxygenation in respiratory failure from a variety of aetiologies, thus avoiding escalation to more invasive supports 3
- HFNC may have a lower intubation rate at day 7 compared to NIV, which includes BiPAP, in patients with acute hypoxemic respiratory failure due to COVID-19 pneumonia 4
Comparison of HFNC and BiPAP in Treating Pneumonia
- There is limited direct comparison between HFNC and BiPAP in treating pneumonia, but HFNC has been shown to be effective in reducing dyspnoea and improving oxygenation in respiratory failure 3
- A study comparing HFNC and NIV (which includes BiPAP) in acute hypoxemic respiratory failure due to COVID-19 pneumonia found that HFNC may have a lower intubation rate at day 7 4
- The evidence suggests that HFNC may be a viable alternative to BiPAP in treating pneumonia, but more research is needed to confirm this 2, 4