The role for high flow nasal cannula as a respiratory support strategy in adults: a clinical practice guideline

Bram Rochwerg, Sharon Einav, Dipayan Chaudhuri, Jordi Mancebo, Tommaso Mauri, Yigal Helviz, Ewan C Goligher, Samir Jaber, Jean-Damien Ricard, Nuttapol Rittayamai, Oriol Roca, Massimo Antonelli, Salvatore Maurizio Maggiore, Alexandre Demoule, Carol L Hodgson, Alain Mercat, M Elizabeth Wilcox, David Granton, Dominic Wang, Elie Azoulay, Lamia Ouanes-Besbes, Gilda Cinnella, Michela Rauseo, Carlos Carvalho, Armand Dessap-Mekontso, John Fraser, Jean-Pierre Frat, Charles Gomersall, Giacomo Grasselli, Gonzalo Hernandez, Sameer Jog, Antonio Pesenti, Elisabeth D Riviello, Arthur S Slutsky, Renee D Stapleton, Daniel Talmor, Arnaud W Thille, Laurent Brochard, Karen E A Burns, Bram Rochwerg, Sharon Einav, Dipayan Chaudhuri, Jordi Mancebo, Tommaso Mauri, Yigal Helviz, Ewan C Goligher, Samir Jaber, Jean-Damien Ricard, Nuttapol Rittayamai, Oriol Roca, Massimo Antonelli, Salvatore Maurizio Maggiore, Alexandre Demoule, Carol L Hodgson, Alain Mercat, M Elizabeth Wilcox, David Granton, Dominic Wang, Elie Azoulay, Lamia Ouanes-Besbes, Gilda Cinnella, Michela Rauseo, Carlos Carvalho, Armand Dessap-Mekontso, John Fraser, Jean-Pierre Frat, Charles Gomersall, Giacomo Grasselli, Gonzalo Hernandez, Sameer Jog, Antonio Pesenti, Elisabeth D Riviello, Arthur S Slutsky, Renee D Stapleton, Daniel Talmor, Arnaud W Thille, Laurent Brochard, Karen E A Burns

Abstract

Purpose: High flow nasal cannula (HFNC) is a relatively recent respiratory support technique which delivers high flow, heated and humidified controlled concentration of oxygen via the nasal route. Recently, its use has increased for a variety of clinical indications. To guide clinical practice, we developed evidence-based recommendations regarding use of HFNC in various clinical settings.

Methods: We formed a guideline panel composed of clinicians, methodologists and experts in respiratory medicine. Using GRADE, the panel developed recommendations for four actionable questions.

Results: The guideline panel made a strong recommendation for HFNC in hypoxemic respiratory failure compared to conventional oxygen therapy (COT) (moderate certainty), a conditional recommendation for HFNC following extubation (moderate certainty), no recommendation regarding HFNC in the peri-intubation period (moderate certainty), and a conditional recommendation for postoperative HFNC in high risk and/or obese patients following cardiac or thoracic surgery (moderate certainty).

Conclusions: This clinical practice guideline synthesizes current best-evidence into four recommendations for HFNC use in patients with hypoxemic respiratory failure, following extubation, in the peri-intubation period, and postoperatively for bedside clinicians.

Keywords: Extubation; High flow nasal cannula; Mortality; Peri-intubation; Postoperative; Respiratory failure.

Conflict of interest statement

SE received funding for travel, given lectures, owns patents with and/or performed consultancy work for Zoll, Medtronic and Diasorin and has participated in multicentre trials run by Artisanpharma, Eisai and Astra Zeneca. JM received personal fees from Faron Pharmaceuticals, Medtronic and Janssen; IMT Medical provided travel and hotel expenses to attend a meeting; he is a coinvestigator on a PAV + multinational trial funded by the CIHR in partnership with Covidien (Medtronic); more than 3 years ago Fisher-Paykel, General Electric and A-Lung provided grant funding to conduct clinical research. TM received lecture fees from Drager, Fisher and Paykel, Mindray and BBraun. EG supported by an Early Career Investigator award from the Canadian Institutes of Health Research. He receives financial and nonfinancial support from Getinge and Timpel outside the submitted work. SJ received Consulting fees from Drager, Xenios, and Fisher & Paykel. J-DR received travel expenses and accommodation coverage from Fisher&Paykel Healthcare to attend scientific meetings. Fisher&Paykel Healthcare provided support for the ongoing High Flow ACRF trial (NCT03406572) but took no part in design or conduct of the study. NR received travel expenses and lecture fees from Fisher&Paykel. OR’s institution received fees for consultation from Hamilton Medical and received lecture fees from Air Liquide. MA’s institution received unrestricted research grant from Fisher & Paykel and GE Healthcare, he received consulting fees from Getinge and Intersurgical. SMM received consulting fees from Draeger Medical and General Electric Healthcare; his Institution received a research grant from Fisher and Paykel Healthcare (the RINO trial, clinicaltrials.gov NCT02107183). AD reports research grants from Philips, Respinor, Lungpacer, French Ministry of Health, Fisher and Paykel Healthcare (the RINO trial, clinicaltrials.gov NCT02107183), financial and nonfinancial support from Fisher&Paykel (including payment for lectures and registration to one scientific meeting), personal fees from Baxter (board meeting), Hamilton (lecture), Getinge (lecture), Lowenstein (advisory board). CH was supported by a Heart Foundation Fellowship. AM received personal fees from Faron Pharmaceuticals, Air Liquid Medical Systems, Pfizer, Resmed and Draeger and grants and personal fees from Fisher and Paykel and Covidien. EA has received fees for lectures from Gilead, Pfizer, Baxter, and Alexion. His research group has been supported by Ablynx, Fisher & Paykel, Jazz Pharma, and MSD. GC received consulting fees from Maquet. AD-M reports research grants from Fisher Paykel, Baxter, Philips, Ferring and GSK; participation to advisory board for Air Liquide, Baxter, and Amomed, lectures for Getinge and Addmedica. JF received grant funding and travel support to meetings from Fisher Paykel ( no role in research from FP) and Xenios. His research group has received research support from CSL, Timpel, Draeger. J-PF received travel expenses and lectures fees from Fisher&Paykel and SOS oxygene. GG received travel expenses and lecture fees from Getinge, Draeger Medical, MSD, Fisher&Paykel, Thermofisher and Biotest. GH received personal fees and travel expenses from Fisher and Paykel Healthcare. AT received financial and nonfinancial support from Fisher&Paykel (including payment for lectures and travel expense coverage to attend scientific meetings), and received financial support from Covidien, Maquet-Getinge, and GE Healthcare outside the submitted work. LB conducts an investigator-initiated trial on PAV + funded by the Canadian Institute for Health Research in partnership with Medtronic Covidien. His laboratory also received grants and non-financial support from Fisher & Paykel, non-financial support from Air Liquide, non-financial support from Philips, non-financial support from Sentec, other from General Electric.

Figures

Fig. 1
Fig. 1
Scheme of recommendations

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