1. The use of high-flow nasal oxygen therapy
(HFNOT) outside critical care – a deanery wide survey
Dr P T Thorburn1, Dr I Francis and Dr F Baldwin
1Brighton and Sussex University Hospitals Trust, RSCH, Eastern Road BN2 5BE. Correspondence
Introduction
High-flow nasal oxygen therapy (HFNOT) is widely used in adult critical care for managing respiratory failure. It was first noted to have a therapeutic effect in neonates largely due to providing continuous positive airways pressure (CPAP), humidified gases and its ability to deliver high FiO2(1). The same CPAP effect has been seen in adults and from this HFNOT has rapidly become ubiquitous in critical care environments across the UK (2). It has been shown to reduce intubation requirements and mortality rate in certain populations (3). HFNOT is a relatively simple intervention requiring low nursing input compared to other forms of ventilatory assistance such as NIV and IPPV. Delivery of HFNOT has expanded to outside the critical care environment but the extent of this has yet to be quantified. Our aim was to quantify the location and logistics of HFNOT delivery within the Kent Surrey and Sussex Deanery. s
Methods
We developed a simple survey via Survey Monkey ( that was circulated to all FICM college tutors within KSS. Questions focussed on where HFNOT is used within the hospital and what the perceived barriers are to its use outside critical care
Our aim was to gauge current practice in an effort to guide service development within our own Trust.
Figure 1 - The word cloud below highlights some of the perceived barriers to using HFNOT outside critical care.
Discussion
The use of HFNOT within KSS is no longer exclusive to the critical care environment. Clearly, its use in ED can be explained as a bridging therapy for those who are waiting admission to critical care. The high use in PACU is also expected as more anaesthetic support and high nursing numbers are common. What is more interesting is the growing use of HFNOT in the ward environment (red in table 1).
Training needs to be structured and targeted in order to reduce the risk of delayed recognition of the deteriorating patient. Suitable escalation plans need to be in place should HFNOT be unsuccessful, providing another opportunity to discuss this with patients and their family in a timely manner. For those sites that do not offer HFNOT in ward environments, this survey shows that it is common practice in KSS and could potentially reduce delayed step-down from critical care if the correct training and processes are implemented.
Results
We achieved a 81% response rate (13/16). HFNOT was frequently used outside critical care (table 1). Interestingly only 54% have 24/7 critical care outreach services. The most attractive feature of HFNOT was thought to be the application of PEEP followed by patient comfort with 100% of responses ranking these features either 1st or 2nd. Training for HFNOT was provided by critical care outreach nurses in 75% of sites. There were 3 sites where HFNOT was not used on regular wards. 70% of respondents stated HFNOT was being used on specific respiratory wards and 62% on AMU or CCU. The most frequent limit on FiO2 and flow rate on regular wards was 0.6 and 60l/min but 2 out of the 10 sites thon regular wards had no upper limit of therapy.
References
1. N Ashraf-Kashani, R Kumar; High-flow nasal oxygen therapy, BJA Education, Volume 17, Issue 2, 1 February 2017, Pages 57–62.
2. Parke R, McGuinness S, Eccleston M. Nasal high-flow therapy delivers low level positive airway pressure. British journal of anaesthesia Dec 1;103(6):
3. Frat JP, Thille AW, Mercat A, Girault C, Ragot S, Perbet S, Prat G, Boulain T, Morawiec E, Cottereau A, Devaquet J. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. New England Journal of Medicine Jun 4;372(23):