Heated, humidified high-flow nasal cannula (HHHFNC) is commonly used as a noninvasive mode of respiratory support in the NICU to avoid prolonged ventilator support and ventilator-induced lung injury. HHHFNC delivers humidified heated and blended oxygen/air at flow rates greater than 1L/min via nasal cannula. The mechanisms of how HHHFNC works include flushing out the nasal airway, providing some positive end-expiratory pressure, and conditioning the gas. Benefits of HHHFNC include improved comfort for babies, less abdominal distension than CPAP, and easier access for procedures. HHHFNC is considered insufficient support if a baby has

1. Heated Humidified High-
Flow Nasal Cannula
By
Dr. Asmaa Abd El wakeel I brahim
Lecturer of Pediatrics/Neonatology
Al-Azhar Faculty of Medicine for Girls

4. • Respiratory failure remains a common problem in the
NICU. Concerns with ventilator-induced lung injury
have led to a concerted effort in many NICUs to avoid
prolonged ventilator support through early
application of noninvasive modes of respiratory
support. Heated, humidified high-flow nasal cannula
(HHHFNC) is commonly used as a noninvasive mode
of respiratory support in the NICU

5. • The use of increased nasal cannula (NC) flow to
deliver positive airway pressure was initially
described by Locke et al. in 1991 in 13 preterm
infants. They reported the potential to deliver
positive pressure with NC flows up to 2 L per minute
(lpm), given a large NC diameter (3 mm). They
cautioned about indiscriminate use of higher flow
rates via NC due to potential for unregulated pressure
delivery.

6. • Ten years later Sreenan et al used the term “high-
flow nasal cannula” in reporting that NC flows up to
2.5 lpm could be as effective as nCPAP for treating
apnea of prematurity.

7. • High flow nasal cannula (HFNC) refers to the delivery
of humidified heated and blended oxygen/air at flow
rates greater than 1L/min via nasal cannula.
• HFNC can be used for
• Non-invasive ventilation of extremely preterm /
preterm infants
• Non-invasive ventilation for infants with
parenchymal lung disease (HMD/pneumonia/CLD/
MAS/ pulmonary hypoplasia/ bronchiolitis)
• Treatment/prevention of apnoea of prematurity .

8. • How does HF work?
• The mechanisms of how High Flow works are
multiple and probably have differential contributions
at different gestations and disease cycles.
• Flush is an important and novel concept, and flush is
improved by having small nasal prongs to allow leak.

9. • How does HF work?
• Gas conditioning – the evidence is that unconditioned
(i.e. gas that is not fully humidified or at 37 degrees)
causes adverse compliance changes in lung tissue
• HFNC provides some PEEP – the evidence is about 4
cm H2O up to 8 litres/min. However this is not a CPAP
device, and we are not controlling nor weaning PEEP.

10. Benefits include
•Babies on HFNC appear to be well settled and more
comfortable than babies on CPAP.
•Less abdominal gaseous distension than CPAP
•Babies do not require “time off” for nose breaks or
changes between nasal prongs / masks,
reducing the amount of handling.

11. Benefits include
•Some evidence for better weight gain and improved
feed tolerance.
•Parents have reported preferring being able to see
more of their babies face.
•Easier access for cranial ultrasound scans and head
circumference measurements.

12. When to decide HHHFNC is not providing sufficient
support:
•Recurrent / persistent apnoea
•Increasing FiO2
•Increasing work of breathing
•Increasing pCO2 / TcCO2 causing acidosis
may indicate that the baby is not responding well to
Vapotherm treatment
.

13. Setting up the Vapotherm:
• Attach appropriate sized nasal cannula. Cannula
should not obstruct or be larger than ½ the diameter of
the nares.
•Adjust the flow to the desired rate and place the
cannula on the patient. Operational flow ratesrange
from 1-8 L/min
•Start at flow rate of 7 L/min.

14. Setting up the Vapotherm:
• Increasing flow (maximum 8L/min): flow can be
increased in increments of 0.5-1 L/min to try to treat
increasing oxygen requirements or apnoea of
prematurity. However other causes(sepsis, worsening
RDS, pneumothorax, exhaustion etc should be
considered) .
• If the baby is requiring FiO2>60%, or has significant
persisting respiratory acidosis (pH<7.2) or apnoea s/he
is likely to need alternative support.

15. Nursing:
• Minimal handling, quiet and dark appropriately
humidified environment
• Monitoring of heart rate, respiratory rate and SaO2 as
a minimum
• Blood pressure monitoring intermittently unless
UAC/arterial line in place
• Prone position, tilted head up to minimize work of
• breathing
• Nasogastric tube should ensure that nostril not
occluded and than tube does not ‘pull’ nares towards
cheek.

16. 1. Bhandari V et al. Synchronized nasal intermittent
positive-pressure ventilation and neonatal outcomes.
Pediatrics. 2009 Aug;124(2):517-26.
2. Wilkinson D J. Pharyngeal pressure with high-flow
nasal cannula Perinatol 2008;28(1):42-47
3. Saslow JG et al Work of breathing using high-flow
nasal cannula in preterm infants. J. Perinatol
2006;26(8):476-480
4. personal communication (Dr. K Ives, Neonatal
Consultant, Oxford John Radcliffe)
5. Spence KL et al. High flow nasal cannula as a device
to provide continuous positive airway pressure in
infants. J Perinatol 2007;27(12):772-77

17. !! THANK YOU !!