ACP on how to use high-flow
By Stacey Butterfield
High-flow nasal oxygen (HFNO) is a new enough intervention that Nick Fitterman, MD, MACP, will explain what it is, complete with visual aids, before he describes ACP’s new guideline on the subject during an Internal Medicine Meeting 2021: Virtual Experience microsession on Saturday, from 11:30 to 11:45 a.m. ET.
"It supplies warm, humidified oxygen through these soft, pliable, wide nasal cannula. It supplies oxygen at up to 60 L/min," said Dr. Fitterman, a coauthor of the guideline and professor at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell in Hempstead, N.Y.
The new guideline, published by Annals of Internal Medicine on April 27, includes two specific recommendations:
· ACP suggests that clinicians use HFNO rather than noninvasive ventilation in hospitalized adults for the management of acute hypoxemic respiratory failure (conditional recommendation; low-certainty evidence).
· ACP suggests that clinicians use HFNO rather than conventional oxygen therapy for hospitalized adults with postextubation acute hypoxemic respiratory failure (conditional recommendation; low-certainty evidence).
The recommendations were based on an accompanying systematic review that compared HFNO to noninvasive ventilation (n=11) and conventional oxygen therapy (n=21). Compared with noninvasive ventilation, HFNO may reduce all-cause mortality, intubation, and hospital-acquired pneumonia and may improve patient comfort in initial management, but not in postextubation management, the review found. The comparison with conventional oxygen showed that HFNO may reduce the risk of reintubation and improve patient comfort after extubation.
In both comparisons, the review authors found that the evidence was of low certainty but that HFNO also appeared to be associated with less harm than the alternative interventions.
The review authors also noted that many aspects of HFNO use, including treatment protocols, clinician and health system training, and cost, have yet to be thoroughly studied. “These represent a key part of HFNO utility for a health system,” they wrote. “Broad applicability, including required clinician and health system experience and resource use, remains unknown.”
As Dr. Fitterman will explain during his talk, the guideline development process is lengthy enough that it was already well under way before the pandemic started. "No one even knew what COVID-19 is, so we have to deviate from the guidelines to address this a little bit," he said, before offering his own experience and some research data comparing HFNO and noninvasive ventilation by helmet in patients with COVID-19.
"I would still pick high-flow over the helmet, but this reduced need for intubation with the helmet [found in a recent trial] deserves further study," said Dr. Fitterman. The ACP guideline does note that HFNO is an aerosol-generating procedure and requires higher grades of personal protective equipment (respiratory protective devices). ■