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Table 1 Most relevant studies of high flow nasal cannula oxygen (HFNC)

From: High-flow nasal cannula support therapy: new insights and improving performance

Condition Author [ref] Design Patients Main results
Acute respiratory failure (ARF) Roca et al. [19] Retrospective cohort 37 lung transplant recipients readmitted to ICU due to ARF (40 episodes) The absolute risk reduction for MV with HFNC was 29.8%, and the NNT to prevent one intubation with HFNC was 3. Multivariate analysis showed that HFNC therapy was the only variable at ICU admission associated with a decreased risk of MV (OR 0.11 [95% CI 0.02–0.69]; p = 0.02)
Frat et al. [20] Randomized controlled trial 313 ARF patients randomly assigned to HFNC, conventional oxygen therapy or NIV The hazard ratio for death at 90 days was 2.01 (95% CI 1.01 to 3.99) with conventional oxygen therapy vs HFNC (p = 0.046) and 2.50 (95% CI, 1.31 to 4.78) with NIV vs HFNC (p = 0.006). In the subgroup of patients with a PaO2/FiO2 ≤ 200 mmHg, the intubation rate was significantly lower in the HFNC group
Rello et al. [31] Retrospective cohort 35 patients with ARF due to H1N1 viral pneumonia After 6 h of HFNC, non‐responders had a lower PaO2/FiO2. All 8 patients on vasopressors required intubation
Lemiale et al. [29] Randomized controlled trial 100 immunocompromised patients with ARF randomized to a 2 h of HFNC vs conventional oxygen No differences in NIV or invasive MV during the 2 h period were observed.
No differences in secondary outcomes (RR, HR, comfort, dyspnea and thirst) were observed
Mokart et al. [42] Retrospective propensity‐score analysis 178 cancer patients admitted to the ICU due to severe ARF HFNC‐NIV was associated with more VFD and less septic shock occurrence.
Mortality of patients treated with HFNC 35 vs 57% for patients never treated with HFNC, p = 0.008
Kang et al. [30] Retrospective cohort 175 patients who failed on HFNC and required intubation In propensity‐adjusted and ‐matched analysis, early intubation (<48 h) was associated with better overall ICU mortality [adjusted OR = 0.317, p = 0.005; matched OR = 0.369, p = 0.046]
Frat et al. [23] Post‐hoc analysis of a randomized controlled trial 82 immunocompromised patients of the FLORALI study NIV was associated with higher risk of intubation and mortality
Roca et al. [32] Prospective cohort 157 patients with severe pneumonia ROX index, defined as ratio of SpO2/FiO2 to respiratory rate, ≥ 4.88 measured after 12 h of HFNC was significantly associated with lower risk for MV (HR 0.273 [95% CI 0.121–0.618])
Coudroy et al. [25] Retrospective cohort 115 immunocompromised patients The rates of intubation and 28‐day mortality were significantly higher in patients treated with NIV than with HFNC
Cardiac surgery Parke et al. [18] Randomized 60 patients with non‐severe hypoxemic ARF were randomized to receive HFNC or oxygen therapy HFNC patients tended to need NIV less frequently (10 vs 30%; p = 0.10) and had significantly fewer desaturations (p = 0.009)
Parke et al. [38] Randomized controlled trial 340 patients after cardiac surgery randomized to HFNC vs conventional oxygen therapy for 48 h No differences in oxygenation on Day 3 after surgery were observed, but HFNC did reduce the requirement for escalation of respiratory support (OR 0.47, 95% CI 0.29–0.7, p = 0.001)
Corley et al. [39] Randomized controlled trial 155 extubated patients with BMI ≥ 30 kg/m2 received conventional oxygen therapy or HFNC No difference was seen between groups in atelectasis. There was no difference in mean PaO2/FiO2 ratio or RR. Five patients failed allocated treatment in the control group compared with three in the treatment group (OR 0.53; 95% CI 0.11, 2.24, p = 0.40)
Stephan et al. [28] Randomized noninferiority trial 830 cardiothoracic surgical patients who developed ARF or were deemed at risk for respiratory failure after extubation. HFNC vs BiPAP The treatment failed in 87 (21.0%) of 414 patients with HFNC and 91 (21.9%) of 416 patients with BiPAP (p = 0.003). No significant differences were found for ICU mortality (23 patients with BiPAP [5.5%] and 28 with HFNC [6.8%]; p = 0.66)
Pre‐intubation Vourc’h et al. [43] Randomized controlled trial 124 patients with PaO2/FIO2 ratio < 300 mmHg, RR ≥ 30 bpm and FIO2 ≥ 0.5. Randomized to HFNC or facial mask No differences in the lowest saturation was observed (HFNC 91.5% vs high flow facial mask 89.5%; p = 0.44). There was no difference in difficult intubation, VFD, intubation‐related adverse events including desaturation < 80% or mortality
Post‐extubation Maggiore et al. [37] Randomized controlled trial 105 patients with PaO2/FiO2 ≤ 300 before extubation who were randomized to 48 h of conventional oxygen therapy or HFNC HFNV improved the PaO2/FiO2 ratio, comfort, airway dryness, episodes of interface displacements, oxygen desaturations, reintubation rate, or any form of ventilator support
Rittayamai et al. [44] Randomized crossover study 17 patients were randomized after extubation to sequential HFNC and conventional oxygen therapy for 30 min periods At the end of the study, patients with HFNC reported less dyspnea and lower RR and HR. Most of the subjects (88.2%) preferred HFNC to conventional oxygen therapy
Tiruvoipati et al. [36] Randomized crossover study 50 patients were randomized to sequential HFNC and facial mask after extubation There was no significant difference in gas exchange, RR or hemodynamics. HFNC was better tolerated (p = 0.01) and tended to be more comfortable (p = 0.09)
Hernandez et al. [1] Randomized controlled trial 527 extubated patients without any high‐risk factor for reintubation were randomized to either HFNC or conventional oxygen therapy for 24 h Reintubation within 72 h was less common in the high‐flow group, 4.9 vs 12.2% in the conventional group (p = 0.004). Postextubation respiratory failure was less common in the high‐flow group 8.3 vs 14.4% in the conventional group (p = 0.03)
Hernandez et al. [5] Randomized non‐inferiority trial 604 extubated patients with at least one high‐risk factor for reintubation were randomized to either HFNC or NIV for 24 h Reintubation within 72 h was noninferior in the HFNC group compared to the NIV group (22.8 vs 19.1%, absolute difference, −3.7%; 95% CI −9.1% to ∞); postextubation respiratory failure was lower in the HFNC group (26.9 vs 39.8%, risk difference, 12.9%; 95% CI 6.6% to ∞)
Invasive procedures Lucangelo et al. [45] Randomized controlled trial 45 patients were randomly assigned to 3 groups: Venturi mask, nasal cannula, and HFNC during bronchoscopy At the end of bronchoscopy, HFNC‐treated patients had higher PaO2/FiO2, and SpO2
Simon et al. [46] Randomized controlled trial 40 patients with hypoxemic ARF received NIV or HFNC during bronchoscopy NIV group had better oxygenation. Two patients with HFNC were unable to proceed to bronchoscopy due to progressive hypoxemia
Heart failure Roca et al. [9] Prospective cohort 10 adult patients with NYHA class III and left ventriclar ejection fraction 45% or less Median inspiratory IVC collapse significantly (p < 0.05) decreased from baseline (37%) to HFNC with 20 l/min (28%) and HFNC with 40 l/min (21%). Changes in IVC inspiratory collapse were reversible
Emergency department Rittayamai et al. [15] Randomized comparative study 40 hypoxemic patients were randomized to receive HFNC or conventional oxygen for 1 h HFNC improved dyspnea and comfort.
No serious adverse events related to HFNC were observed
Jones et al. [47] Randomized controlled trial 303 hypoxemic and tachypneic patients admitted to the lemergency department 5.5% of HFNC patients vs 11.6% of conventional oxygen therapy patients required MV within 24 h of admission (p = 0.053)
  1. MV mechanical ventilation, RR respiratory rate, ICU intensive care unit, ARF acute respiratory failure, VFD ventilator‐free days, NNT number needed to treat, COT conventional oxygen therapy, NIV non‐invasive ventilation, HR heart rate, BMI body mass index, IVC inferior vena cava