What are the guidelines for using Vapotherm (high-flow nasal cannula therapy) in patients?

Guidelines for Using Vapotherm (High-Flow Nasal Cannula) in Patients

High-flow nasal cannula (HFNC) therapy should be used over conventional oxygen therapy for patients with acute hypoxemic respiratory failure and over noninvasive ventilation in hospitalized adults for management of acute hypoxemic respiratory failure. 1

Indications for HFNC Therapy

HFNC therapy is indicated for:

• Patients with acute hypoxemic respiratory failure 1
• Postextubation respiratory support in high-risk patients 1
• Patients with moderate to severe dyspnea despite conventional oxygen 2
• Patients requiring high FiO₂ or showing increased work of breathing 2
• Patients who remain uncomfortable on conventional oxygen therapy 2

Physiological Benefits of HFNC

HFNC offers several physiological advantages over conventional oxygen therapy:

• Delivers increased FiO₂ with greater stability 1
• Provides a CPAP effect of approximately 7 cm H₂O at 50 L/min flow 1
• Improves oxygenation and reduces respiratory rate 1, 2
• Reduces anatomical dead space and improves carbon dioxide washout 3
• Decreases work of breathing 2, 3
• Enhances patient comfort and reduces dyspnea 1, 2
• Improves secretion clearance through heated humidification 2, 3

Initial Settings and Setup

• Flow rate: Start at 40-50 L/min, can be increased up to 60 L/min 1, 2
• FiO₂: Titrate to maintain SpO₂ ≥ 92% 2
• Temperature: Set to 37°C for optimal humidification 4
• Interface: Use nasal cannula specifically designed for high-flow application 1

Clinical Outcomes and Evidence

Compared to Conventional Oxygen Therapy (COT)

• Reduces risk of intubation (risk ratio 0.89) 2
• Reduces risk of reintubation in postextubation patients (4.9% vs 12.2%) 1
• Improves patient comfort and reduces dyspnea 1, 2
• Increases PaO₂ values by approximately 16.72 mmHg 2
• May increase ICU length of stay but potentially reduces overall hospital costs 1

Compared to Noninvasive Ventilation (NIV)

• Better tolerated by patients 1
• Similar efficacy in preventing intubation in acute hypoxemic respiratory failure 1
• Easier to use and requires less expertise 3

Special Populations

Immunocompromised Patients

• Effects on mortality similar to general population 1
• May not show the same reduction in intubation rates as seen in immunocompetent patients 1

Postextubation Support

• Particularly beneficial in high-risk patients (those with COPD, CHF, hypercapnia, older age) 1
• Should be applied immediately after extubation to realize outcome benefits 1
• Reduces reintubation rates compared to conventional oxygen therapy 1

Monitoring and Safety

• Monitor for signs of respiratory deterioration
• Watch for nasal irritation or soreness (common side effect) 1
• May not work effectively if nose is severely congested or blocked 1
• No increased risk of barotrauma compared to conventional oxygen therapy 1

Common Pitfalls and Caveats

• Not specifying adequate flow rates: Flow rates below 40 L/min may not provide sufficient CPAP effect or washout of dead space
• Inadequate humidification: Ensure proper heating and humidification to prevent mucosal drying
• Delayed escalation: Have clear criteria for when to escalate to NIV or intubation if HFNC fails
• Inappropriate patient selection: HFNC may delay necessary intubation in rapidly deteriorating patients
• Inadequate monitoring: Despite comfort, patients may still have progressive respiratory failure requiring closer monitoring

Resource Considerations

• While material cost and oxygen use are higher than conventional oxygen therapy, avoiding intubation may result in overall cost savings 1
• In resource-constrained settings, prioritize HFNC for patients at highest risk of intubation 1
• In the UK, HFNC resulted in cost savings of £156 compared to COT, with higher savings of £727 in high-risk patients 1

HFNC therapy represents an important advancement in respiratory support that bridges the gap between conventional oxygen therapy and more invasive ventilation methods, with demonstrated benefits for patient comfort, oxygenation, and potentially reduced intubation rates.