The effects of flow settings during high-flow nasal cannula support for adult subjects: a systematic review

Jie Li, Fai A Albuainain, Wei Tan, J Brady Scott, Oriol Roca, Tommaso Mauri, Jie Li, Fai A Albuainain, Wei Tan, J Brady Scott, Oriol Roca, Tommaso Mauri

Abstract

Background: During high-flow nasal cannula (HFNC) therapy, flow plays a crucial role in the physiological effects. However, there is no consensus on the initial flow settings and subsequent titration. Thus, we aimed to systematically synthesize the effects of flows during HFNC treatment.

Methods: In this systematic review, two investigators independently searched PubMed, Embase, Web of Science, Scopus, and Cochrane for in vitro and in vivo studies investigating the effects of flows in HFNC treatment published in English before July 10, 2022. We excluded studies that investigated the pediatric population (< 18 years) or used only one flow. Two investigators independently extracted the data and assessed the risk of bias. The study protocol was prospectively registered with PROSPERO, CRD42022345419.

Results: In total, 32,543 studies were identified, and 44 were included. In vitro studies evaluated the effects of flow settings on the fraction of inspired oxygen (FIO2), positive end-expiratory pressure, and carbon dioxide (CO2) washout. These effects are flow-dependent and are maximized when the flow exceeds the patient peak inspiratory flow, which varies between patients and disease conditions. In vivo studies report that higher flows result in improved oxygenation and dead space washout and can reduce work of breathing. Higher flows also lead to alveolar overdistention in non-dependent lung regions and patient discomfort. The impact of flows on different patients is largely heterogeneous.

Interpretation: Individualizing flow settings during HFNC treatment is necessary, and titrating flow based on clinical findings like oxygenation, respiratory rates, ROX index, and patient comfort is a pragmatic way forward.

Keywords: Flow settings; High-flow nasal cannula; Oxygen therapy; Oxygenation; Patient self-inflicted lung injury; Peak inspiratory flow; Ventilation distribution.

Conflict of interest statement

JL discloses research funding from Fisher & Paykel Healthcare Ltd., Aerogen Ltd., and Rice Foundation, and speaker fees from American Association for Respiratory Care, Aerogen Ltd., Heyer Ltd., and Fisher & Paykel Healthcare Ltd. JL also serves as section editor for Respiratory Care. JBS discloses research funding from Teleflex and speaker fees from Aerogen and Medline Industries, LP. OR discloses a research grant from Hamilton Medical and speaker fees from Hamilton Medical, Ambu, Fisher & Paykel Ltd., and Aerogen Ltd., and non-financial research support from Timpel. TM discloses personal fees from Fisher and Paykel, Draeger Medical, Hamilton and Mindray. FA and WT have no conflict of interest to disclose.

© 2023. The Author(s).

Figures

Fig. 1
Fig. 1
Study flow diagram. HFNC, high-flow nasal cannula
Fig. 2
Fig. 2
Relationship between FIO2 and flow ratio of HFNC flow to peak inspiratory flow during tidal breathing. FIO2, fraction of inspired oxygen; HFNC, high-flow nasal cannula
Fig. 3
Fig. 3
Effects of mouth status (open- vs closed-mouth breathing) (A, B), lung compliance (B), gas type (C), and nasal prong size (C) on PEEP levels. PEEP, positive end-expiratory pressure; HFNC, high-flow nasal cannula
Fig. 4
Fig. 4
Relationship between CO2 clearance and HFNC flow settings. CO2, carbon dioxide; HFNC, high-flow nasal cannula
Fig. 5
Fig. 5
The relationship between airway pressures and HFNC flow settings. HFNC, high-flow nasal cannula
Fig. 6
Fig. 6
Effects of flow settings on Δ Pes (A), PTP (B), and WOB (C). HFNC, high-flow nasal cannula; Δ Pes: esophageal pressure swings (cmH2O); PTP: esophageal pressure–time product per minute (cmH2O·s/min); WOB, work of breathing (J/min)

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