From the Guidelines
High flow nasal cannula (HFNC) is recommended over non-invasive ventilation (NIV) and conventional oxygen therapy (COT) for the management of acute hypoxemic respiratory failure in hospitalized adults, due to its ability to provide heated and humidified oxygen at high flow rates, improve patient comfort, and reduce the work of breathing 1.
Key Differences Between HFNC, NIV, and COT
- HFNC delivers heated, humidified oxygen at high flow rates (up to 60 L/min) through nasal prongs, washing out dead space, reducing work of breathing, and providing a small amount of positive pressure.
- NIV delivers positive pressure ventilation through a tight-fitting mask (like CPAP or BiPAP) and provides stronger respiratory support with set inspiratory and expiratory pressures.
- COT includes low-flow systems (nasal cannulae or masks) and high-flow systems (masks), but does not provide the same level of respiratory support as HFNC or NIV.
Clinical Applications
- HFNC is typically used for mild to moderate respiratory distress, and is comfortable, allowing patients to eat and speak.
- NIV is more effective for conditions like COPD exacerbations, cardiogenic pulmonary edema, and more severe hypoxemic respiratory failure, but requires more monitoring and can cause skin breakdown from mask pressure.
- The choice between HFNC and NIV depends on the severity of respiratory failure, patient comfort, and specific clinical condition.
Evidence-Based Recommendations
- The European Respiratory Society (ERS) recommends the use of HFNC over COT and NIV in hypoxaemic acute respiratory failure, based on a systematic review and meta-analysis of clinical trials 1.
- The American College of Physicians (ACP) also suggests the use of HFNC over NIV and COT in hospitalized adults with acute hypoxemic respiratory failure, although the evidence is considered low-certainty 1.
From the Research
Overview of Oxygen Therapy Options
- High-flow (HF) oxygen therapy, nasal cannula (NC) oxygen therapy, and non-invasive ventilation (NIV) are different methods of providing oxygen support to patients with respiratory failure 2, 3, 4.
- HF oxygen therapy delivers oxygen at high flows with optimal heat and humidification, reducing anatomical dead space and improving carbon dioxide wash-out 2.
- NC oxygen therapy provides a lower flow of oxygen compared to HF therapy and is often used for patients with mild respiratory distress 5.
- NIV, on the other hand, provides a higher level of respiratory support and is typically used for patients with more severe respiratory failure 3, 4.
Comparison of HF, NC, and NIV
- HF oxygen therapy has been shown to be effective in reducing dyspnoea and improving oxygenation in patients with respiratory failure, avoiding the need for more invasive supports 2, 5.
- NIV is highly effective in supporting patients with hypercapnic respiratory failure, but its use requires specific expertise and can be poorly tolerated by patients 2, 3.
- HF oxygen therapy has been proposed as an alternative to NIV in some cases, but its use is not without limitations, and NIV should be preferred if not contraindicated 3.
- The choice between HF, NC, and NIV depends on the individual patient's needs and clinical condition, with factors such as the severity of respiratory distress, underlying diagnosis, and patient tolerance playing a crucial role 4, 5, 6.
Clinical Applications of HF, NC, and NIV
- HF oxygen therapy has been used to treat a variety of clinical conditions, including hypoxaemic respiratory failure, exacerbation of chronic obstructive pulmonary disease (COPD), postintubation hypoxaemia, and palliative respiratory care 2, 5.
- NIV is commonly used to support patients with hypercapnic respiratory failure, including those with COPD and other conditions yielding muscle dysfunction 3.
- NC oxygen therapy is often used in the emergency department setting for patients with acute hypoxemic respiratory failure, including those with pneumonia, acute respiratory distress syndrome (ARDS), and coronavirus disease 2019 (COVID-19) 5.
- HF oxygen therapy has also been used in do-not-intubate patients with hypoxemic respiratory distress, providing an effective alternative to NIV in some cases 6.