The use of noninvasive ventilation (NIV) and CPAP is associated with poor adherence rates due to a variety of factors, including mask discomfort, anxiety, and disruption to daily living.1 This has led caregivers to consider alternative strategies when treating respiratory diseases that have been traditionally treated with these modalities.
High-flow nasal cannula (HFNC) therapy is a form of respiratory support in which heated, humidified air is delivered at high flows, with or without supplemental oxygen, through specially designed nasal prongs. HFNC may be better tolerated by patients who experience discomfort with the use of traditional NIV or CPAP. Possible mechanisms by which HFNC provides respiratory support include washout of carbon dioxide from the nasopharyngeal airway, delivery of fixed oxygen concentrations, improved mucociliary clearance, generation of small positive end-expiratory pressure, reduction of nasopharyngeal flow resistance, and conditioning of respiratory gas.2 Several devices in the United States can deliver home HFNC with airflow rates between 10 and 60 liters per minute (LPM) and oxygen flow rates of up to 15 LPM.
Several studies have examined the efficacy of HFNC in treating chronic hypercapnic respiratory failure due to COPD. In a systematic review of four clinical trials comparing home nocturnal HFNC with standard oxygen therapy in patients with COPD and chronic hypercapnia, Pitre and colleagues found that home HFNC was associated with a reduced number of acute exacerbations and improved quality of life but no statistically significant effect on mortality.3 Importantly, the mean PaCO2 in these studies ranged from 48.3 to 51.9 mm Hg, and, therefore, the impact of home HFNC in patients with more severe hypercapnia is unknown.
Long-term use of HFNC may also reduce acute exacerbations in patients with bronchiectasis4 and improve exertional tolerance in patients with idiopathic pulmonary fibrosis.5 However, the evidence for these indications is very limited.
Home HFNC has also been used in pediatric respiratory disease, although no controlled studies have been performed to date. Ehrlich and colleagues reviewed the use of home HFNC in 75 children (median age, 8 months). HFNC was used for a variety of indications, including OSA, tracheobronchomalacia, nonspecific chronic lung disease, and neuromuscular disease. There was a high level of parental satisfaction, and no adverse events related to HFNC therapy were observed.6 Hawkins and colleagues performed polysomnography in 10 children with moderate to severe OSA and found that HFNC support was associated with a reduced obstructive apnea-hypopnea index, improved oxygenation, and reduced heart rate.7 Another study found HFNC and CPAP therapy to be equally effective in treating OSA in 18 children with obesity and medical complexity.8
While home HFNC therapy is a promising treatment option for chronic respiratory failure, more prospective studies are needed to identify which patients would benefit most from this approach. Specifically, noninferiority studies comparing HFNC with NIV or CPAP would be invaluable.
References
1. Volpato E, Banfi PI, Pagnini F. Acceptance and adherence to non-invasive positive pressure ventilation in people with chronic obstructive pulmonary disease: a grounded theory study. Front Psychol. 2023;14:1134718.
2. Nolasco S, Manti S, Leonardi S, Vancheri C, Spicuzza L. High-flow nasal cannula oxygen therapy: physiological mechanisms and clinical applications in children. Front Med (Lausanne). 2022;9:920549.
3. Pitre T, Abbasi S, Su J, Mah J, Zeraatkar D. Home high flow nasal cannula for chronic hypercapnic respiratory failure in COPD: a systematic review and meta-analysis. Respir Med. 2023;219:107420.
4. Good WR, Garrett J, Hockey HUP, Jayaram L, Wong C, Rea H. The role of high-flow nasal therapy in bronchiectasis: a post hoc analysis. ERJ Open Res. 2021;7(1):00711-2020.
5. Harada J, Nagata K, Morimoto T, et al. Effect of high-flow nasal cannula oxygen therapy on exercise tolerance in patients with idiopathic pulmonary fibrosis: a randomized crossover trial. Respirology. 2022;27(2):144-151.
6. Ehrlich S, Tripto IG, Lavie M, et al. High flow nasal cannula therapy in the pediatric home setting. Pediatr Pulmonol. 2023;58(3):941-948.
7. Hawkins S, Huston S, Campbell K, Halbower A. High-flow, heated, humidified air via nasal cannula treats CPAP-intolerant children with obstructive sleep apnea. J Clin Sleep Med. 2017;13(8):981-989.
8. Fishman H, Al-Shamli N, Sunkonkit K, et al. Heated humidified high flow nasal cannula therapy in children with obstructive sleep apnea: a randomized cross-over trial. Sleep Med. 2023;107:81-88.