Positively Pressured: Nasal Cannulas in the Respiratory Toolkit

There are a lot of options when it comes to providing oxygenation and ventilatory support to our patients.  With so many non-invasive options, host Dr. Kate Joyce sits down with Dr. Jeremy Greenberg to talk about nasal cannula options that may be helpful to many of our patients in the ED. 

OVERVIEW

The FLORALI Trial (Clinical Effect of the Association of Noninvasive Ventilation and High-Flow Nasal Oxygen Therapy in Resuscitation of Patients with Acute Lung Injury)

Although there are ongoing subsequent studies, the FLORALI trial randomly assigned 310 patients WITHOUT hypercapnia who had acute hypoxemic respiratory failure to high-flow oxygen therapy, standard oxygen therapy through a face mask, or noninvasive positive-pressure ventilation. They evaluated the proportion of patients intubated at day 28, all-cause mortality in the ICU and at 90 days and the number of ventilator-free days at day 28. Check out the NEJM article, but in brief - among the three methods studied, there was no significant difference in intubation rates. Additionally, there was a significant difference in favor of high-flow oxygen in 90-day mortality.  However, be sure to consider whether or not the study results apply to the patient in front of you!

• EM Crit, Josh Farkas, 2015: Pneumonia, BiPAP, secretions, and HFNC: New lessons from FLORALI
• Frat JP, 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.  
• Frat JP, Ricard JD, Coudroy R, Robert R, Ragot S, Thille AW. Preoxygenation with non-invasive ventilation versus high-flow nasal cannula oxygen therapy for intubation of patients with acute hypoxaemic respiratory failure in ICU: the prospective randomised controlled FLORALI-2 study protocol. BMJ open. 2017;12(7): e018611. 
• Frat JP, Ricard JD, Quenot JP, et al. Non-invasive ventilation versus high-flow nasal cannula oxygen therapy with apnoeic oxygenation for preoxygenation before intubation of patients with acute hypoxaemic respiratory failure: a randomised, multicentre, open-label trial. Lancet Respir Med. 2019;7(4):303-312. 
• Coudroy R, Frat JP, Ehrmann S, et al. High-flow nasal oxygen therapy alone or with non-invasive ventilation in immunocompromised patients admitted to ICU for acute hypoxemic respiratory failure: the randomised multicentre controlled FLORALI-IM protocol. BMJ open. 2019;9(8): e029798. 
• Frat JP, Coudroy R, Marjanovic N, Thille AW. High-flow nasal oxygen therapy and noninvasive ventilation in the management of acute hypoxemic respiratory failure. Ann Transl Med. 2017;5(14):297. 

Online Resources

• REBEL EM, Frank Lodeserto, 2018 & 2020, High Flow Nasal Cannula (HFNC) Parts 1 & 2:
  • How It Works: https://rebelem.com/high-flow-nasal-cannula-hfnc-part-1-how-it-works/
  • Overview of High Flow Nasal Cannula: https://rebelem.com/rebel-crit-cast-episode-2-0-overview-of-high-flow-nasal-cannula-hfnc-part-1/
  • Adult & Pediatric Indications https://rebelem.com/high-flow-nasal-cannula-hfnc-part-2-adult-pediatric-indications-2/
• REBEL EM, Jenny Beck-Esmay, 2020, Is All Oxygen Created Equal? https://rebelem.com/is-all-oxygen-created-equal/
• High Velocity Nasal Cannula: vapotherm.com
• EM Crit, Josh Farkas, 2018: Mastering the dark arts of BiPAP & HFNC: https://emcrit.org/pulmcrit/bipap-hfnc/ 

Peer-Reviewed Literature

• Chaudhuri D, Jinah R, Burns KEA, et al. Helmet non-invasive ventilation compared to facemask non-invasive ventilation and high flow nasal cannula in acute respiratory failure: a systematic review and meta-analysis. Eur Respir J. 2021;2101269.
• Drake MG. High-flow nasal cannula oxygen in adults: an evidence-based assessment. Ann Am Thorac Soc. 2018;15(2):145-155.
• Doshi P, Whittle JS, Bublewicz M, et al. High-Velocity Nasal Insufflation in the Treatment of Respiratory Failure: A Randomized Clinical Trial. Ann Emerg Med. 2018;72(1):73-83.e5.
• Hernández G, Vaquero C, Colinas L, et al. Effect of Postextubation High-Flow Nasal Cannula vs Noninvasive Ventilation on Reintubation and Postextubation Respiratory Failure in High-Risk Patients A Randomized Clinical Trial. JAMA. 2016;316(15):1565-1574.  
• Marjanovic N, Guenezan J, Frat JP, Mimoz O, Thille AW. High-flow nasal cannula oxygen therapy in acute respiratory failure at Emergency Departments: A systematic review. Am J Emerg Med. 2020;38(7):1508-1514. 
• Nishimura M. High-flow nasal cannula oxygen therapy in adults: physiological benefits, indication, clinical benefits, and adverse effects. Respir Care. 2016;61(4):529-541. 

High Velocity and High Flow Nasal Cannulas in Sepsis

• Surviving Sepsis Campaign 2021: Evans, Laura, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021;47(11):1181-1247. 
• Tongyoo S, Tantibundit P, Viarasilpa T, Permpikul C, Udompanturak S. High-flow nasal oxygen cannula vs. noninvasive mechanical ventilation to prevent reintubation in sepsis: a randomized controlled trial. Ann Intensive Care. 2021;11(1):135.

High Velocity and High Flow Nasal Cannula in Pediatrics

• Ralston SL. High-flow nasal cannula therapy for pediatric patients with bronchiolitis: time to put the horse back in the barn. JAMA Pediatr. 2020;174(7):635-636.
• Weiler T, Kamerkar A, Hotz J, et al. The Relationship between High Flow Nasal Cannula Flow Rate and Effort of Breathing in Children. J Pediatr. 2017;189:66-71.e3.