1) High flow nasal cannula (HFNC) delivers humidified oxygen at up to 60 L/min through nasal prongs. It is indicated for hypoxic respiratory failure from conditions like pneumonia. 2) Studies show HFNC improves oxygenation and lowers respiratory rate compared to conventional oxygen therapy. It may help prevent intubation and has been used successfully for peri-intubation and post-extubation. 3) However, HFNC is not a reliable form of PEEP and should not delay intubation in severely ill patients. Further research is still needed on its optimal uses.

1. NASAL HIGH FLOW
Dr Nisar Ahmed Arain
Assistant Professor
Anesthesia/Critical care/ER

2. High Flow Nasal Cannula and
Humidification

3. OVER VIEW
-Risks
- Respiratoryfailure
- Preventingintubation
-Peri-intubation
- Post extubationtherapy
- Questions
-What is HFNC
- KeyPoints
-Indications
-Contraindications
-Complications
-Positiveeffects

4. •Oxygen and air source
•Air-oxygen blender generates up
to FiO2 1.0 at a flow rate of up to
60L/min
•Active heated humidifier capable of
providing 100% body humidity
•Single limb heated inspiratory
circuit (avoids heat loss and
condensation)
•Lightweight, flexible delivery tubing
•Adjustable head strap
•Soft and flexible nasal prongs
•Different brands are available (e.g.
Optiflow™)
High Flow Nasal Cannula (Opti flow)

5. Key Points
-The amount of oxygen
patients get depends on
their inspiratory flow rate.
-Masks do notdeliver
consistent levels of
oxygen, where as HFNC
does.
-Deadspace is washed out
during its application
-Is not a reliable form of
PEEP

6. Indications
Hypoxic respiratory failure
-Community-acquired
pneumonia
-Viral pneumonia (e.g.influenza)
-Acute asthma
-Cardiogenic pulmonary edema
-Pulmonaryembolism
-Interstitialpneumonia
-Carbon monoxidepoisoning
Also needed for High FiO2
oxygen delivery in the
following conditions
-
-
1-before and after intubation
2-post cardiac surgery
3-oxygen supply during
invasive procedures
a-Trans-oral endoscopy
(TOE) upper GI
b-Endoscopy

7. -Contraindications
-Epistaxis
-Baseof skull fracture
-Surgery to the nose or
upper aero digestive
tract
-Nasal obstruction e.g.
nasal fracture, tenacious
secretions,tumour

8. Complications
- Local trauma, discomfort and
pressure areas
- Epistaxis
- Gastricdistension
- Blocked cannulae due to
secretions

9. Positive effects

10. should be a two hour limit on HFNC
Risks
-He is doing ok on that,lets not
intubate……
- In patients who are acutely
unwell with high oxygen/flow
rates, trial
- It should NOT delayintubation
- Failure of HFNC might cause
delayed intubation and worse
clinical outcomes in patients
with respiratory failure. e

11. Respiratory failure (Type 1)
-Gold standard for Type 2 is still
BiPAP
- No bigstudies yet
-One small study comparedtreating
patients in acute respiratory
failure with facemasks and HFNC
- They found that the HFNC
improved the patients PaO2and
was associated wIthalower
respiratory rate

12. Respiratory failure continued
- A second study evaluated the efficiency, safety
and outcome of high flow nasal cannula
oxygen (HFNC) in ICU patients with acute
respiratory failure
- HFNC significantly reduced the respiratory rate,
heart rate and increased pulse oximetry
-These improvements were observed as early as
15M after the beginning of HFNC for respiratory
rate and pulse oximetery. PaO2 and PaO2/FiO2
increased significantly after one hour, HNFC in
comparison with base line

13. Preventing intubation
-One study compared standard therapy
NIV and HFNC in patients with type 1
respiratory failure
-They found the intubation rate was
lower in the HFNC group (38% of
patients compared with 47% in the
standard and 50% in the NIV group)
but this was not statistically
significant.
- It did show an improvement in
ventilator free days and 90 day
mortality

14. Preventing intubation
-A study which looked at
respiratory failure in do not
intubate patients treated
with HFNC first and escalated
to NIV if HFNCfailed
-The study showed that HFNC
was effective in increasing
oxygen saturations and
lowered respiratory rate.
-9 of the 50 (18%) patients
recruited had to be
escalated to NIV

15. Peri-intubation
-Preoxygenation andapnoeic
Oxygenation
- Compared to HFFM (high
flow face mask), HFNCasa
preoxygenation device did
not reduce the lowest level
of desaturation in an RCT
(Vour’ch et al, 2015 –
PREOXYFLOW trial)

16. -Peri-intubation continued
- A case series of 25 patients with
difficult airways undergoing
general anesthesia for
hypopharyngeal or
laryngotracheal surgery had
mean apnoea times of 14
minutes without desaturation
(i.e. SaO2 >90)

17. Post extubation therapy
-Evidence is coming through that we
should be extubating onto HFNCin
all patient
- Compared to facemask, in low risk
patients, at the same FiO2 aswhen
ventilated, there were less episodes
of desaturation (75% to 40%) and
reintubation rates were reduced
(21% to 4%). (Maggiore et al, 2014)

18. Post extubation therapy continued
-A second study compared highand
low risk patients extubated onto
“conventional oxygen therapy” and
optiflow
-Compared to the conventional therapy
patients experienced lower rates of
respiratory failure leading to
reintubation ( 12% to 5%)

19. CLEANING
-We all know how to clean an
Optiflow, hopefully!!
-What about weaning? 2hours
on 2 hours off
- Do you need a newset
-When you do
- When you don’t

20. STOP THEPRESSES!!
--A meta analysis published in late
2017 showed that HFNCis
superior to standard oxygen
therapy in preventing intubation
--It also showed no diffrence in
intubation rates between HFNC
and NIV
-- The recommend further RCT’s

21. Conclusion
-What HFNCis
-What its goodfor
-What its not good for
-Should HFNCbe our first line
treatment for Type 1RF
-Good or bad forperi-intubation
-Should we extubate onto HFNC
routinely

22. Questions & Discussion

23. THANK YOU