NHF clinical practice guidelines underscore the true breadth of nasal high flow (HFNC) therapy application

Published recommendations underscore the breadth of nasal high flow therapy application

Data from hundreds of controlled trials have been consolidated into clinical practice guidelines and recommendations.

Review guidelines below

Research interest in NHF is increasing. Over the past decade >350 publications per year (on average) have been cataloged on PubMed.

A significant number of controlled trials, systematic reviews and meta-analyses are included.

Medical societies around the world are now in a position to create recommendations that may change clinical practice.

Clinical applications/ scenarios

AARC
Guideline 2021

AARC: Piraino et al. Management of Adult Patients With Oxygen in the Acute Care Setting. Respir Care. 2021 Nov 2:respcare.09294. doi: 10.4187/respcare.09294. Epub ahead of print. PMID: 34728574. https://pubmed.ncbi.nlm.nih.gov/34728574/

ESICM
Guideline 2020

ESICM: Rochwerg et al. The role for high flow nasal cannula as a respiratory support strategy in adults: a clinical practice guideline. Intensive Care Med. 2020 Dec;46(12):2226-2237. doi: 10.1007/s00134-020-06312-y. Epub 2020 Nov 17. PMID: 33201321; PMCID: PMC7670292. https://pubmed.ncbi.nlm.nih.gov/33201321/

ERS
Guideline 2022

Oczkowski et al. ERS clinical practice guidelines: high-flow nasal cannula in acute respiratory failure. Eur Respir J. 2022 Apr 14;59(4):2101574. doi: 10.1183/13993003.01574-2021. PMID: 34649974. https://pubmed.ncbi.nlm.nih.gov/34649974/

SSC
Guideline 2021

Evans et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021 Nov;47(11):1181-1247. doi: 10.1007/s00134-021-06506-y. Epub 2021 Oct 2. PMID: 34599691; PMCID: PMC8486643. https://pubmed.ncbi.nlm.nih.gov/34599691/

WHO
Guideline 2022

Clinical management of COVID-19: Living guideline, 23 June 2022. Geneva: World Health Organization; 2022 (WHO/2019-nCoV/Clinical/2022.1). Available from: https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2022-1/ [Accessed 12 September 2022]

ACP
Guideline 2021

Qaseem et al. Appropriate Use of High-Flow Nasal Oxygen in Hospitalized Patients for Initial or Postextubation Management of Acute Respiratory Failure: A Clinical Guideline From the American College of Physicians. Ann Intern Med. 2021 Jul;174(7):977-984. doi: 10.7326/M20-7533. Epub 2021 Apr 27. PMID: 33900796. https://pubmed.ncbi.nlm.nih.gov/33900796/https://pubmed.ncbi.nlm.nih.gov/33900796/

TSANZ
Guideline 2022

Barnett et al. Thoracic Society of Australia and New Zealand Position Statement on Acute Oxygen Use in Adults: 'Swimming between the flags'. Respirology. 2022 Apr;27(4):262-276. doi: 10.1111/resp.14218. Epub 2022 Feb 17. PMID: 35178831. https://pubmed.ncbi.nlm.nih.gov/35178831/

JARDS Guideline 2022

Tasaka et al. ARDS Clinical Practice Guideline 2021 committee from the Japanese Society of Intensive Care Medicine, the Japanese Respiratory Society, and the Japanese Society of Respiratory Care Medicine. ARDS Clinical Practice Guideline 2021. J Intensive Care. 2022 Jul 8;10(1):32. doi: 10.1186/s40560-022-00615-6. PMID: 35799288; PMCID: PMC9263056. https://pubmed.ncbi.nlm.nih.gov/35799288/

PRIMARY SUPPORT - MEDICAL

Patients with: Acute respiratory failure (ARF)	General recommendations for the delivery of supplemental oxygen forpatients who require oxygen (AARC).Aim for SpO2 range of 94–98% for most of hospitalized patients (included critically ill patients) ---- Aim for 88–92% for patients with COPD ---- Aim for 88–95% for patients with ARDS ---- Consider early initiation of NHF. RECOMMENDATION based on the collective experience. https://pubmed.ncbi.nlm.nih.gov/34728574/
Acute respiratory distress syndrome (ARDS)								ARDS (Joint committee of 3 Japanese societies) We suggest conducting non-invasive respiratory support (NPPV, HFNC) instead of conventional oxygen therapy as an initial respiratory management for adult patients with acute respiratory failure suspected of having ARDS if there are no contraindications for non-invasive respiratory support or if organ failure other than respiratory failure is absent. NPPV (weak recommendation/moderate certainty of evidence: GRADE 2B). HFNC (weak recommendation/moderate certainty of evidence: GRADE 2B).Recommendation (CQ 16) https://pubmed.ncbi.nlm.nih.gov/35799288/
Acute hypoxemic respiratory failure (AHRF)		Acute hypoxemic respiratory failure (ESICM): NHF is preferred to conventional oxygen therapy (COT) for patients with hypoxemic respiratory failure. STRONG RECOMMENDATION https://pubmed.ncbi.nlm.nih.gov/33201321/	Acute hypoxemic respiratory failure (ERS): NHF is preferred to COT or NIV in patients with acute hypoxemic respiratory failure. CONDITIONAL RECOMMENDATION. https://pubmed.ncbi.nlm.nih.gov/34649974/			Acute hypoxemic respiratory failure (ACP): NHF is preferred to NIV in patients with AHRF. CONDITIONAL RECOMMENDATION. https://pubmed.ncbi.nlm.nih.gov/33900796/	Oxygen delivery (TSANZ): hNHF-O2 may be used in patients with acute, severe, hypoxaemic respiratory failure (Grade B) 35178831. https://pubmed.ncbi.nlm.nih.gov/35178831/
Acute hypercapnic respiratory failure			Acute hypercapnic respiratory failure (ERS): Trialling NIV prior to use of NHF in patients with COPD or acute hypercapnic respiratory failure. CONDITIONAL RECOMMENDATION. https://pubmed.ncbi.nlm.nih.gov/34649974/
Sepsis-induced AHRF				Hospitalized patients with severe or critical COVID-19 and acute hypoxaemic respiratory failure (WHO): use [NHF] rather than standard oxygen therapy. CONDITIONAL RECOMMENDATION. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2022-1
Patients with severe or critical COVID-19					Recommendations regarding ventilation (SSC): NHF is preferred to NIV in patients with sepsis-induced hypoxemic respiratory failure. WEAK RECOMMENDATION. https://pubmed.ncbi.nlm.nih.gov/34599691/
Patients who are immunocompromised with AHRF	Immunocompromised (AARC): Either NHF or COT may be used in patients who require supplemental oxygen. RECOMMENDATION based on scientific experience. https://pubmed.ncbi.nlm.nih.gov/34728574/

PRIMARY SUPPORT - SURGICAL

Low risk post-operative patients		Post‑operative (ERS): Either NHF or COT can be used in post-operative patients at low risk of respiratory complications. CONDITIONAL RECOMMENDATION. https://pubmed.ncbi.nlm.nih.gov/34649974/
High risk post-operative patients		Post‑operative (ERS): Either NHF or NIV can be used in postoperative patients at high risk of respiratory complications. CONDITIONAL RECOMMENDATION.https://pubmed.ncbi.nlm.nih.gov/34649974/
High risk post-cardiothoracic surgery patients	Post-operative (ESICM): NHF is preferred to COT in high risk and/or obese patients undergoing cardiac or thoracic surgery to prevent respiratory failure in the immediate postoperative period. CONDITIONAL RECOMMENDATION. https://pubmed.ncbi.nlm.nih.gov/33201321/

PRE-ESCALATION SUPPORT

Pre-oxygenation for peri-intubation patients

Peri-intubation (ESICM): NO RECOMMENDATION is made regarding the use of NHF in the peri-intubation period. NHF during intubation should be continued for patients who are already receiving NHF. CONTINUE NHF. https://pubmed.ncbi.nlm.nih.gov/33201321/

DE-ESCALATION SUPPORT

Post-extubation	Post‑extubation (AARC) NHF is preferred to COT immediately post-extubation in patients who require supplemental oxygen. RECOMMENDATION based on scientific experience. https://pubmed.ncbi.nlm.nih.gov/34728574/	Post-extubation respiratory failure (ESICM): NIPPV is preferred to NHF in patients who would normally be extubated to NIPPV. CONDITIONAL RECOMMENDATION. https://pubmed.ncbi.nlm.nih.gov/33201321/		Post‑extubation (ACP): NHF is preferred to COT in patients with post-extubation AHRF. CONDITIONAL RECOMMENDATION. https://pubmed.ncbi.nlm.nih.gov/33900796/
Low risk, extubated patients			Post‑extubation (ERS): HFNC over COT in non-surgical patients at low risk of extubation failure. CONDITIONAL RECOMMENDATION. https://pubmed.ncbi.nlm.nih.gov/34649974/
High risk, extubated patients		Post-extubation respiratory failure (ESICM): NHF is preferred to COT following extubation in patients with any high-risk feature who were intubated for >24 hours. . CONDITIONAL RECOMMENDATION. https://pubmed.ncbi.nlm.nih.gov/33201321/	Post‑extubation (ERS): NIV is preferred to NHF in non-surgical patients at high risk of extubation failure, unless NIV is contra-indicated. CONDITIONAL RECOMMENDATION. https://pubmed.ncbi.nlm.nih.gov/34649974/

COMPLEMENTARY RESPIRATORY SUPPORT

NIV-rested AHRF patients

Breaks from NIV (ERS): NHF is preferred to COT during breaks from NIV in patients with acute hypoxemic respiratory. failure. CONDITIONAL RECOMMENDATION. https://pubmed.ncbi.nlm.nih.gov/34649974/

PROPHYLACTIC RESPIRATORY SUPPORT

Patients requiring oxygen for any reason

14. General recommendations for the delivery of supplemental oxygen for patients who require oxygen (AARC). Aim for SpO2 range of 94–98% for most of hospitalized patients (included critically ill patients) ---- Aim for 88–92% for patients with COPD ---- Aim for 88–95% for patients with ARDS ---- Consider early initiation of NHF. RECOMMENDATION
based on the collective experience. https://pubmed.ncbi.nlm.nih.gov/34728574/
27. Avoid escalation (AARC) NHF is preferred to COT to avoid escalation to NIV or IV in patients who require supplemental oxygen. RECOMMENDATION based on scientific experience. https://pubmed.ncbi.nlm.nih.gov/34728574/

Latest Flow Matters Edition

Clinical Practice guidelines

Download PDF for an overview of this page

References and recommendations

Acute hypoxemic respiratory failure (ESICM): NHF is preferred to conventional oxygen therapy (COT) for patients with hypoxemic respiratory failure. STRONG RECOMMENDATION https://pubmed.ncbi.nlm.nih.gov/33201321/
Peri-intubation (ESICM): NO RECOMMENDATION is made regarding the use of NHF in the peri-intubation period. NHF during intubation should be continued for patients who are already receiving NHF. CONTINUE NHF. https://pubmed.ncbi.nlm.nih.gov/33201321/
Post-extubation respiratory failure (ESICM): NIPPV is preferred to NHF in patients who would normally be extubated to NIPPV. CONDITIONAL RECOMMENDATION. https://pubmed.ncbi.nlm.nih.gov/33201321/
Post-operative (ESICM): NHF is preferred to COT in high risk and/or obese patients undergoing cardiac or thoracic surgery to prevent respiratory failure in the immediate postoperative period. CONDITIONAL RECOMMENDATION. https://pubmed.ncbi.nlm.nih.gov/33201321/
Acute hypoxemic respiratory failure (ERS): NHF is preferred to COT or NIV in patients with acute hypoxemic respiratory failure. CONDITIONAL RECOMMENDATION. https://pubmed.ncbi.nlm.nih.gov/34649974/
Acute hypercapnic respiratory failure (ERS): Trialling NIV prior to use of NHF in patients with COPD or acute hypercapnic respiratory failure. CONDITIONAL RECOMMENDATION. https://pubmed.ncbi.nlm.nih.gov/34649974/
Post‑extubation (ERS): HFNC over COT in non-surgical patients at low risk of extubation failure. CONDITIONAL RECOMMENDATION. https://pubmed.ncbi.nlm.nih.gov/34649974/
Post‑operative (ERS): Either NHF or COT can be used in post-operative patients at low risk of respiratory complications. CONDITIONAL RECOMMENDATION. https://pubmed.ncbi.nlm.nih.gov/34649974/
Breaks from NIV (ERS): NHF is preferred to COT during breaks from NIV in patients with acute hypoxemic respiratory. failure. CONDITIONAL RECOMMENDATION. https://pubmed.ncbi.nlm.nih.gov/34649974/
Recommendations regarding ventilation (SSC): NHF is preferred to NIV in patients with sepsis-induced hypoxemic respiratory failure. WEAK RECOMMENDATION. https://pubmed.ncbi.nlm.nih.gov/34599691/
Avoid escalation (AARC): NHF is preferred to COT to avoid escalation to NIV or IV in patients who require supplemental oxygen. RECOMMENDATION based on scientific experience. https://pubmed.ncbi.nlm.nih.gov/34728574/
Post‑extubation (AARC) NHF is preferred to COT immediately post-extubation in patients who require supplemental oxygen. RECOMMENDATION based on scientific experience. https://pubmed.ncbi.nlm.nih.gov/34728574/
Immunocompromised (AARC): Either NHF or COT may be used in patients who require supplemental oxygen. RECOMMENDATION based on scientific experience. https://pubmed.ncbi.nlm.nih.gov/34728574/
General recommendations for the delivery of supplemental oxygen for patients who require oxygen (AARC). Aim for SpO2 range of 94–98% for most of hospitalized patients (included critically ill patients) ---- Aim for 88–92% for patients with COPD ---- Aim for 88–95% for patients with ARDS ---- Consider early initiation of NHF. RECOMMENDATION
based on the collective experience. https://pubmed.ncbi.nlm.nih.gov/34728574/
Acute hypoxemic respiratory failure (ACP): NHF is preferred to NIV in patients with AHRF. CONDITIONAL RECOMMENDATION. https://pubmed.ncbi.nlm.nih.gov/33900796/
Post‑extubation (ACP): NHF is preferred to COT in patients with post-extubation AHRF. CONDITIONAL RECOMMENDATION. https://pubmed.ncbi.nlm.nih.gov/33900796/
Oxygen delivery (TSANZ): hNHF-O2 may be used in patients with acute, severe, hypoxaemic respiratory failure (Grade B) 35178831. https://pubmed.ncbi.nlm.nih.gov/35178831/
Post‑operative (ERS): Either NHF or NIV can be used in postoperative patients at high risk of respiratory complications. CONDITIONAL RECOMMENDATION.https://pubmed.ncbi.nlm.nih.gov/34649974/
Post-extubation respiratory failure (ESICM): NIPPV is preferred to NHF in patients who would normally be extubated to NIPPV. CONDITIONAL RECOMMENDATION. https://pubmed.ncbi.nlm.nih.gov/33201321/
ESICM: Rochwerg et al. The role for high flow nasal cannula as a respiratory support strategy in adults: a clinical practice guideline. Intensive Care Med. 2020 Dec;46(12):2226-2237. doi: 10.1007/s00134-020-06312-y. Epub 2020 Nov 17. PMID: 33201321; PMCID: PMC7670292. https://pubmed.ncbi.nlm.nih.gov/33201321/
Oczkowski et al. ERS clinical practice guidelines: high-flow nasal cannula in acute respiratory failure. Eur Respir J. 2022 Apr 14;59(4):2101574. doi: 10.1183/13993003.01574-2021. PMID: 34649974.https://pubmed.ncbi.nlm.nih.gov/34649974/
Evans et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021 Nov;47(11):1181-1247. doi: 10.1007/s00134-021-06506-y. Epub 2021 Oct 2. PMID: 34599691; PMCID: PMC8486643. https://pubmed.ncbi.nlm.nih.gov/34599691/
AARC: Piraino et al. Management of Adult Patients With Oxygen in the Acute Care Setting. Respir Care. 2021 Nov 2:respcare.09294. doi: 10.4187/respcare.09294. Epub ahead of print. PMID: 34728574. https://pubmed.ncbi.nlm.nih.gov/34728574/
Qaseem et al. Appropriate Use of High-Flow Nasal Oxygen in Hospitalized Patients for Initial or Postextubation Management of Acute Respiratory Failure: A Clinical Guideline From the American College of Physicians. Ann Intern Med. 2021 Jul;174(7):977-984. doi: 10.7326/M20-7533. Epub 2021 Apr 27. PMID: 33900796. https://pubmed.ncbi.nlm.nih.gov/33900796/https://pubmed.ncbi.nlm.nih.gov/33900796/
Barnett et al. Thoracic Society of Australia and New Zealand Position Statement on Acute Oxygen Use in Adults: 'Swimming between the flags'. Respirology. 2022 Apr;27(4):262-276. doi: 10.1111/resp.14218. Epub 2022 Feb 17. PMID: 35178831. https://pubmed.ncbi.nlm.nih.gov/35178831/
Post-extubation respiratory failure (ESICM): NHF is preferred to COT following extubation in patients with any high-risk feature who were intubated for >24 hours. . CONDITIONAL RECOMMENDATION. https://pubmed.ncbi.nlm.nih.gov/33201321/
Avoid escalation (AARC) NHF is preferred to COT to avoid escalation to NIV or IV in patients who require supplemental oxygen. RECOMMENDATION based on scientific experience. https://pubmed.ncbi.nlm.nih.gov/34728574/
Tasaka et al. ARDS Clinical Practice Guideline 2021 committee from the Japanese Society of Intensive Care Medicine, the Japanese Respiratory Society, and the Japanese Society of Respiratory Care Medicine. ARDS Clinical Practice Guideline 2021. J Intensive Care. 2022 Jul 8;10(1):32. doi: 10.1186/s40560-022-00615-6. PMID: 35799288; PMCID: PMC9263056. https://pubmed.ncbi.nlm.nih.gov/35799288/
ARDS (Joint committee of 3 Japanese societies) We suggest conducting non-invasive respiratory support (NPPV, HFNC) instead of conventional oxygen therapy as an initial respiratory management for adult patients with acute respiratory failure suspected of having ARDS if there are no contraindications for non-invasive respiratory support or if organ failure other than respiratory failure is absent. NPPV (weak recommendation/moderate certainty of evidence: GRADE 2B). HFNC (weak recommendation/moderate certainty of evidence: GRADE 2B).Recommendation (CQ 16) https://pubmed.ncbi.nlm.nih.gov/35799288/
Post‑extubation (ERS): NIV is preferred to NHF in non-surgical patients at high risk of extubation failure, unless NIV is contra-indicated. CONDITIONAL RECOMMENDATION. https://pubmed.ncbi.nlm.nih.gov/34649974/
Prior to ETT (Joint committee of 3 Japanese societies) (CQ 18) We suggest conducting HFNC over tracheal intubation as an initial respiratory management for adult patients with acute respiratory failure suspected of having ARDS if there are no contraindications for non-invasive respiratory support or if organ failure other than respiratory failure is absent (weak recommendation/moderate certainty of evidence: GRADE 2B). https://pubmed.ncbi.nlm.nih.gov/35799288/`
Hospitalized patients with severe or critical COVID-19 and acute hypoxaemic respiratory failure (WHO): use [NHF] rather than standard oxygen therapy. CONDITIONAL RECOMMENDATION. https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2022-1
Clinical management of COVID-19: Living guideline, 23 June 2022. Geneva: World Health Organization; 2022 (WHO/2019-nCoV/Clinical/2022.1). Available from: https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2022-1/ [Accessed 12 September 2022]

View references

Subscribe to receive updates related to NHF clinical practice guidelines

If you would like to subscribe to our newsletter, please provide the following information so we can add you to our email list.

Email Address:*

Country/Region:*

I consent to Fisher & Paykel Healthcare keeping me informed about new F&P products, clinical updates, events and promotions on Adult Respiratory Care

Enter security code:*

By submitting this form, you consent to Fisher & Paykel Healthcare storing your personal information to contact you about your enquiry. Your information will be collected and stored securely by Fisher & Paykel Healthcare Limited based in New Zealand and may be shared with the wider Fisher & Paykel Healthcare group as necessary to support your enquiry. We will not share, disclose or sell your information to third parties for marketing purposes. For full details on how we use and manage your personal information, how long we may retain this information for sales or marketing purposes, your rights to access, correct or delete your personal information, and how to contact us about your personal information, please see our privacy statement.

PM-627834_b (page updated 28thSept22)