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Peer-reviewed protocol for use of nasal high flow

The first peer-reviewed protocol for use of nasal high flow has been published, for adult patients with Acute Hypoxemic Respiratory Failure.

Based on some of the most robust clinical trials to date, this protocol provides a suggested approach for selection of patients, titration and weaning of nasal high flow.

View the Pubmed abstract

Download the clinical summary & protocol


The algorithm is a recommendation by the authors and has been reproduced under Creative Commons Licence 4.0. This material is exclusively for healthcare professionals and the information conveyed is intended exclusively for healthcare practitioners and the information conveyed constitutes neither medical advice nor instructions for use. This material should not be used for training purposes or to replace individual hospital policies or practices. Before any product use, consult the appropriate user instructions.

More Evidence

  1. Ward JJ. High-flow oxygen administration by nasal cannula for adult and perinatal patients. Respir Care 2013;58(1):98–122.
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  2. Papazian L, Corley A, Hess D, et al. Use of high-flow nasal cannula oxygenation in ICU adults: a narrative review. Intensive Care Med 2016;
    View abstract
  3. Roca O, Hernández G, Díaz-Lobato S, et al. Current evidence for the effectiveness of heated and humidified high flow nasal cannula supportive therapy in adult patients with respiratory failure. Crit Care 2016;20(1):109.
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  4. Nishimura M. High-flow nasal cannula oxygen therapy in adults. J Intensive Care 2015;3(1):15                          
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  1. Mündel T, Feng S, Tatkov S, Schneider H. Mechanisms of nasal high flow on ventilation during wakefulness and sleep. J Appl Physiol 2013;114(8):1058–1065.
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  2. Möller W, Celik G, Feng S, et al. Nasal high flow clears anatomical dead space in upper airway models. J Appl Physiol 2015;118(12):1525–1532.
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  3. Ritchie JE, Williams AB, Gerard C, Hockey H. Evaluation of a humidified nasal high-flow oxygen system, using oxygraphy, capnography and measurement of upper airway pressures. Anaesth Intensive Care 2011;39(6):1103–1110.
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  4. Hasani A, Chapman TH, McCool D, Smith RE, Dilworth JP, Agnew JE. Domiciliary humidification improves lung mucociliary clearance in patients with bronchiectasis. Chron Respir Dis 2008;5(2):81–86.
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  5. Roca O, Riera J, Torres F, Masclans JR. High-flow oxygen therapy in acute respiratory failure. Respir Care 2010;55(4):408–413.
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  6. Parke R, McGuinness S, Eccleston M. Nasal high-flow therapy delivers low level positive airway pressure. Br J Anaesth 2009;103(6):886–890.
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  7. Parke RL, Eccleston ML, McGuinness SP. The effects of flow on airway pressure during nasal high-flow oxygen therapy. Respir Care 2011;56(8):1151–1155.
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  1. Lenglet H, Sztrymf B, Leroy C, Brun P, Dreyfuss D, Ricard J-D. Humidified high flow nasal oxygen during respiratory failure in the emergency department: feasibility and efficacy. Respir Care 2012;57(11):1873–1878.
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  2. Rittayamai N, Tscheikuna J, Praphruetkit N, Kijpinyochai S. Use of High-Flow Nasal Cannula for Acute Dyspnea and Hypoxemia in the Emergency Department. Respir Care 2015;60(10):1377–1382.
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  3. Peters SG, Holets SR, Gay PC. High-flow nasal cannula therapy in do-not-intubate patients with hypoxemic respiratory distress. Respir Care 2013;58(4):597–600.
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  4. Roca O, Pérez-Terán P, Masclans JR, et al. Patients with New York Heart Association class III heart failure may benefit with high flow nasal cannula supportive therapy: high flow nasal cannula in heart failure. J Crit Care 2013;28(5):741–746.
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  5. Parke R, McGuinness S, Eccleston M. Nasal high-flow therapy delivers low level positive airway pressure. Br J Anaesth 2009;103(6):886–890.
    View abstract
  6. Corley A, Caruana LR, Barnett AG, Tronstad O, Fraser JF. Oxygen delivery through high-flow nasal cannulae increase end-expiratory lung volume and reduce respiratory rate in post-cardiac surgical patients. Br J Anaesth 2011;107(6):998–1004.
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  7. Roca O, Riera J, Torres F, Masclans JR. High-flow oxygen therapy in acute respiratory failure. Respir Care 2010;55(4):408–413.
    View abstract
  8. Sztrymf B, Messika J, Bertrand F, et al. Beneficial effects of humidified high flow nasal oxygen in critical care patients: a prospective pilot study. Intensive Care Med 2011;37(11):1780–1786.
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  9. Fraser JF, Spooner AJ, Dunster KR, Anstey CM, Corley A. Nasal high flow oxygen therapy in patients with COPD reduces respiratory rate and tissue carbon dioxide while increasing tidal and end-expiratory lung volumes: a randomised crossover trial. Thorax 2016;
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  1. Stéphan F, Barrucand B, Petit P, et al. High-Flow Nasal Oxygen vs Noninvasive Positive Airway Pressure in Hypoxemic Patients After Cardiothoracic Surgery: A Randomized Clinical Trial. JAMA 2015;313(23):2331–2339.
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  2. Rea H, McAuley S, Jayaram L, et al. The clinical utility of long-term humidification therapy in chronic airway disease. Respir Med 2010;104(4):525–533.
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  3. Sztrymf B, Messika J, Bertrand F, et al. Beneficial effects of humidified high flow nasal oxygen in critical care patients: a prospective pilot study. Intensive Care Med 2011;37(11):1780–1786.
    View abstract
  4. Maggiore SM, Idone FA, Vaschetto R, et al. Nasal high-flow versus Venturi mask oxygen therapy after extubation. Effects on oxygenation, comfort, and clinical outcome. Am J Respir Crit Care Med 2014;190(3):282–288.
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  5. Frat J-P, Thille AW, Mercat A, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med 2015;372(23):2185–2196.
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  6. Gaunt KA, Spilman SK, Halub ME, Jackson JA, Lamb KD, Sahr SM. High-Flow Nasal Cannula in a Mixed Adult ICU. Respir Care 2015;60(10):1383–1389.
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  7. Hernández G, Vaquero C, González P, et al. Effect of Postextubation High-Flow Nasal Cannula vs Conventional Oxygen Therapy on Reintubation in Low-Risk Patients: A Randomized Clinical Trial. JAMA 2016;315(13):1354–1361.
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  8. Fealy N, Osborne C, Eastwood GM, Glassford N, Hart G, Bellomo R. Nasal high-flow oxygen therapy in ICU: A before-and-after study. Aust Crit Care 2016;29(1):17–22.
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  9. Messika J, Ahmed K Ben, Gaudry S, et al. Use of High-Flow Nasal Cannula Oxygen Therapy in Subjects With ARDS: A 1-Year Observational Study. Respir Care 2015;60(2):162–169.
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  10. Bell N, Hutchinson CL, Green TC, Rogan E, Bein KJ, Dinh MM. Randomised control trial of humidified high flow nasal cannulae versus standard oxygen in the emergency department. Emerg Med Australas 2015
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