Published recommendations reinforce the role of nasal high flow therapy across multiple clinical settings

Goel et al. Am J Respir Crit Care Med. 2026

• We recommend NHF as compared to COT for adults with de novo acute hypoxemic respiratory failure. We suggest NIV via facemask or helmet as compared to COT for adults with de novo acute hypoxemic respiratory failure. 
• We suggest NHF as an alternative to NIV as compared to standard oxygen therapy for patients with acute hypercapnic respiratory failure and mild acidemia (e.g. pH > 7.25) provided that monitoring and escalation to NIV are promptly available. We recommend using NHF or NIV vs COT for preoxygenation in patients with acute respiratory failure undergoing endotracheal intubation. 
• No recommendations for or against NHF compared with NIV. We suggest NHF or NIV vs COT post-extubation in the ICU. We suggest using NIV vs COT or NHF post-extubation in the ICU in patients at high-risk of extubation failure.

Baugh et al. West J Emerg Med. 2025

• In undifferentiated respiratory distress (elevated RR with SpO2 < 92% on maximal supplemental oxygen via standard nasal cannula or facemask that does not meet immediate criteria for intubation) and if not in hypercarbic respiratory failure with pH < 7.25, initiate NHF (flow 50–60 L/min and titrate FiO2 to target SpO2). 

Godwin et al. Annals Emerg Med. 2025 & ACEP Point-of-Care Tool

• For preoxygenation, NIPPV is preferred but NHF with flows > 50 L/min and 100% FiO2 is an alternative. 

Piraino et al. Respir Care. 2022

• In patients requiring supplemental oxygen, the committee supports early initiation of NHF versus late initiation of NHF based on the clinical condition of the patient. Consider humidification for oxygen flows > 4 L/min to improve patient comfort. 
• NHF is preferred to avoid escalation to NIV or invasive ventilation in patients who require supplemental oxygen. 
• Compared to COT, NHF reduces reintubation when used immediately post-extubation. 
  
  

Qaseem et al. Ann Intern Med. 2021

• Suggests that clinicians use NHF rather than NIV in hospitalized adults for the management of acute hypoxemic respiratory failure. 
• Suggests clinicians use NHF rather than COT for hospitalized patients with post-extubation acute hypoxemic respiratory failure.

Oczkowski et al. Eur Respir J. 2022

• Suggests the use of NHF over COT in patients with acute hypoxemic respiratory failure. 
• Suggests a trial of NIV prior to the use of NHF in COPD patients with acute hypercapnic respiratory failure. 
• Suggests the use of either NHF or COT in postoperative patients at low risk of respiratory complications. 
• NHF should be preferred over COT during breaks off NIV in patients with AHRF. NHF or NIV in postoperative patients at high risk of respiratory complications. 
• Suggests the use of NHF over COT in nonsurgical patients after extubation. 
• Suggests NIV over NHF for patients at high risk of extubation failure, unless there are absolute or relative contraindications to NIV.

Rochwerg et al. Intensive Care Med. 2020

• Recommends using NHF compared to COT for patients with hypoxemic respiratory failure. 
• For patients already receiving NHF, we suggest continuing NHF during intubation. 
• We suggest NHF as compared to COT following extubation for patients who are intubated more than 24 hours and have any high-risk feature. For patients who clinicians would normally extubate to NIPPV, we suggest continued use of NIPPV as opposed to NHF. 
• In high-risk and/or obese patients undergoing cardiac or thoracic surgery, we suggest using NHF compared to COT to prevent respiratory failure in the immediate postoperative period.

Grasselli et al. Intensive Care Med. 2023

• We recommend that non-mechanically ventilated patients with AHRF not due to cardiogenic pulmonary edema or AECOPD receive NHF as compared to conventional oxygen therapy to reduce the risk of intubation. This recommendation applies also to AHRF from COVID-19 and to ARDS managed with NHF.

Acquisto et al. Crit Care Med. 2023

• Suggests preoxygenation with NHF when laryngoscopy is expected to be challenging. 
• Suggest preoxygenation with NIPPV in patients with severe hypoxemia (PaO₂/FiO₂ < 150).

Prescott et al. Crit Care Med. 2026

• For adults with sepsis and acute hypoxemic respiratory failure: we suggest using NHF over COT for patients with a PaO₂/FiO₂ ratio < 200 or SpO₂/FiO₂ ratio < 235; we suggest using NHF as the initial therapy over NIPPV; we suggest using NHF over NHF alternating with NIPPV.

Global Strategy for The Diagnosis, Management, and Prevention of COPD 2026 Report. 2026

• NHF is the first mode of ventilation in COPD patients with acute hypoxemic respiratory failure. 
• High flow oxygen systems and mechanical NIV are indicated for patients with COPD and acute respiratory failure because they improve gas exchange, reduce work of breathing and the need for intubation. They also decrease hospitalization duration and improve survival. 
• Indications for NHF: persistent hypoxemia, unable to tolerate NIV; contraindication for NIV; weaning patient off supplemental oxygen following NIV; preventing reintubation in patients requiring intubation and positive pressure ventilation; treatment of patients with stable COPD at risk of exacerbations.