Nasal cannula as a respiratory support strategy in adults: a clinical practice guideline

Key points

• High flow nasal cannula (HFNC) delivers high flow, heated and humidified oxygen at a controlled concentration through the nose; this guideline makes recommendations for four clinical settings.
• HFNC is recommended over conventional oxygen therapy for patients with hypoxemic respiratory failure (strong recommendation, moderate certainty).
• HFNC is suggested following extubation (conditional recommendation, moderate certainty).
• No recommendation is made for HFNC in the peri-intubation period (moderate certainty).
• Postoperative HFNC is suggested for high-risk and/or obese patients after cardiac or thoracic surgery (conditional recommendation, moderate certainty).

Overview

This international clinical practice guideline, endorsed by the European Society of Intensive Care Medicine, synthesises the best current evidence on HFNC as a respiratory support strategy in adults. Conventional oxygen therapy is defined as low-flow oxygen of 15 l/min or less by nasal cannula or face mask. This overview is based on the abstract, methods and recommendation statements of the guideline.

How the recommendations were made

The panel included intensive care physicians, respirologists and clinician-methodologists, and used GRADE and the Evidence-to-Decision framework, considering certainty of evidence, benefits and harms, patient values, resource use, equity, acceptability and feasibility. Strong recommendations are worded as we recommend and conditional ones as we suggest. Members with important financial conflicts of interest (5,000 dollars or more) could join the discussion but did not vote. The recommendations were finalised in Brussels on 4 November 2019.

What the recommendations mean

A strong recommendation means most patients should receive the recommended course of action and it can serve as a quality indicator. A conditional recommendation means different choices are likely to be appropriate for different patients, and therapy should be tailored to the individual circumstances, including patient and family values and preferences.

FAQ

Should HFNC be used instead of standard oxygen in hypoxemic respiratory failure?

Yes. The guideline recommends HFNC over conventional oxygen therapy in hypoxemic respiratory failure (strong recommendation, moderate certainty).

Is HFNC recommended during intubation?

No recommendation was made for the peri-intubation period (moderate certainty evidence).

Who should receive HFNC after surgery?

It is suggested for high-risk and/or obese patients after cardiac or thoracic surgery (conditional recommendation, moderate certainty).

Source

Rochwerg B, Einav S, Chaudhuri D, et al. The role for high flow nasal cannula as a respiratory support strategy in adults: a clinical practice guideline. Intensive Care Med 2020;46(12):2226-2237. DOI: 10.1007/s00134-020-06312-y. © Springer-Verlag GmbH Germany, part of Springer Nature 2020; free access via the PMC COVID-19 collection. Summary prepared by Medpresso from the original publication; it is not a substitute for the full text or for medical advice.