High Flow Nasal Cannula

(HFNC)
Humidified High Flow Nasal Cannula
(HHFNC)
Heated Humidified High Flow Nasal Cannula
(HHHFNC)
NASAL HIGH FLOW THERAPY
(NHFT).
Heated Humidified
High Flow Nasal Cannula
(HHHFNC) Delivery of heated and humidified
blended oxygen at optimal flow
rates directly into the nares via
a non-sealing nasal cannula
 How does
Nasal high flow (NHF) therapy
work ?

Dynamic positive airway

Reduces anatomical dead space
Wash-out of the anatomical dead
space in the nasopharyngeal
cavity is a principal mechanism of
action of NHF
pressure The delivery of dynamic
positive airway pressure associated
with NHF has been shown to reduce
inspiratory effort and
work of breathing compared to
standard oxygen therapy
Improves patient comfort
NHF is gentle on the nose,
which
improves patient comfort,
compliance, and tolerance to
therapy
© 2021 Fisher & Paykel Healthcare Limited
Advances in Neonatal Care 2008 • Vol. 8, No. 2 • pp. 98-106
 Increasing use
Increasing of nHFT
HFNC Use
among US-American
All Patients during NICUNICUs
Stay

2004

2010

(2002)

aris.primadi@yahoo.co.i
d
20 20 20
02 04 10
Evidence Support and Guidelines for Using HFNC in
Neonatology Oxford Nasal High-Flow Therapy
Meeting, 2015
 Use of HFNC in neonates: Nationwide survey in Japan

aris.primadi@yahoo.co.i
d

Indications for use of HFNC in neonates in neonatal care units in Japan.

(■ ) Frequently; ( ) occasionally; ( ) rarely; (□) never.
Heated Humidified High Flow Nasal Cannula
(Indications
HHHFNC) for use
• Post extubation
• Slow to wean off CPAP
• Prevention or management of apnea of prematurity
• Nasal trauma from CPAP prongs
• For babies with signs of mild/moderate respiratory distress
• Respiratory Distress Syndrome
• Chronic Lung Disease
• Other lung conditions such as pneumonia, meconium aspiration
• Requiring > 1 L/min of oxygen therapy (this should not be given un-humidified via low-flow nasal cannula)

Craigavon Area Hospital Northern Ireland, 2015

North Devon District Hospital Barnstaple England,
Heated Humidified High Flow Nasal Cannula
(HHHFNC) Contraindications for use
 Significant active airleak (pneumothorax, pneumomediastinum)
 Frequent apnea despite optimal caffeine therapy
 Upper airway abnormalities
 Severe cardiovascular instability
 Respiratory acidosis (pH < 7.25)

Craigavon Area Hospital Northern Ireland, 2015

North Devon District Hospital Barnstaple England,
Decision to start HFNC therapy in Special
Care Unit

Neonatal FFNC Oxygen Therapy Guideline. North Devon District Hospital; 2018
 Initiating HFNC therapy in Special
CareAttach
Unitoxygen saturation recording,
and select appropriate sized nasal prongs

Set initial flow rate to 6 * A lower flow rate of 5

L/min * smaller
L/min maybabies & up tofor
be sufficient 8
L/min for larger babies
Set initial FiO2 to maintain
saturations: 95-99% in neonates
> 36 w
90-95% in neonates <
36 w ( if in air up to
100% for all )
If oxygen saturations are not satisfactory in >  If respiratory picture settled and normalized gas – senior review and
40% FiO2or other cause for concern eg. try
Oxytogen weanto . be
respiratory effort,  weaned before
for senior alternativ
review and consider  flow.
Oxygen can be weaned to the lowest amount that gives the
e support d
W ehse
ire
ndFisO
atu2rations&ap
25% bpropriate
aby stable withtoappgestation.
ropriate SpO2 then
 switch to low flow
Neonatal FFNC Oxygen Therapy Guideline. North Devon District Hospital; 2018
oxygen therapy if appropriate
 SETTING
Flow Flow Flow
rate 1.000 – 1.999 2.000 – 2.999 rate > 3.000
rate
g g g
3 L/min 4 L/min 5 L/min

The flow rate can be increased within each weight category by a maxm
i um of 3 L/min
above the starting flow rate
FiO2 is initiated at the same value if the infant is on another mode of non-invasive respiratory support but 5-10%
higher if the infant is being extubated

Select correct size of prongs – prongs outer diameter should only occupy ~ 50% of the internal
diameter of the nares

Temperature of humidifier set at 34-37?C

Craigavon Area Hospital Northern Ireland, 2015

 A consistent range of
usage
Below is a visual summary of the flow ranges used in the 3 RCTs published in
2013.
The studies below use starting flows between 3 and 8 L/min.

Less than 32
weeks
gestational age
Premature
and neonatal
cannula

< 2 kg

2-3
kg
>3
1 Collins et al. J. Pediatr. 2013. kg
2Manley et al. New Engl J Med.
2013. 3 Yoder et al. Pediatrics.
2013.
Pharyngeal pressure with high-flow nasal cannulae in
premature infants
Pharyngeal pressure with high-flow nasal cannulae in
premature infants
Averange
pharyngeal
pressure
measured at
2-8 L/min flow

No correlation
between
pharyngeal
pressure and
mouth condition
Recommendations for increasing the
flow rate
FiO2 has increased 10% above the starting FiO2

Increased retractions or distress noted

Decreased lung expansion noted on chest x-ray

pCO2 has increased 1.3kPa above the baseline

value

Craigavon Area Hospital Northern Ireland, 2015

 SETTING
Flow Flow Flow
rate 1.000 – 1.999 2.000 – 2.999 rate > 3.000
rate
g g g
3 L/min 4 L/min 5 L/min

The flow rate can be increased within each weight category by a maxm
i um of 3 L/min above
the starting flow rate

FiO2 is initiated at the same value if the infant is on another mode of NIRS but
5-10% higher if the infant is being extubated

Select correct size of prongs – prongs outer diameter should only

occupy ~ 50% of the internal diameter of the nares

Temperature of humidifier set at 34-37 C Craigavon Area Hospital Northern Ireland, 2015
 SETTING
Flow Flow Flow
rate 1.000 – 1.999 2.000 – 2.999 rate > 3.000
rate
g g g
3 L/min 4 L/min 5 L/min

The flow rate can be increased within each weight category by a maxm
i um of 3 L/min above
the starting flow rate

FiO2 is initiated at the same value if the infant is on another mode of N-IRS but
5-10% higher if the infant is being extubated

Select correct size of prongs – prongs outer diameter should only

occupy ~ 50% of the internal diameter of the nares

Temperature of humidifier set at 34-37 C Craigavon Area Hospital Northern Ireland, 2015
 SETTING
Flow Flow Flow
rate 1.000 – 1.999 2.000 – 2.999 rate > 3.000
rate
g g g
3 L/min 4 L/min 5 L/min

The flow rate can be increased within each weight category by a maxm
i um of 3 L/min above
the starting flow rate

FiO2 is initiated at the same value if the infant is on another mode of N-IRS but
5-10% higher if the infant is being extubated

Select correct size of prongs – prongs outer diameter should only

occupy ~ 50% of the internal diameter of the nares

Temperature of humidifier set at 34-370C

Craigavon Area Hospital Northern Ireland, 2015
Monitoring of a baby on
HFNC
Continuous monitoring of heart rate,
respirations & saturation
Report any signs of increased work of
breathing
May require blood gases & chest X-ray as clinically indicated

Potential for nasal erosion still exists so the nares need to be

checked regularly

Tubing needs to be checked to clear “rainout” Craigavon

as thisAreacaHospital
n causNorthern
e lavagIreland,
e &2015
HFNC Criteria for treatment
failure
Flow 8 lpm

FiO2 0,4

pH < 7.2, pCO2 > 60 mm Hg

Episode of apnea requiring > 2 episodes of PPV within 24-hour period; or

Apnea requiring > 6 episodes of any intervention within 6-hour period

N Engl J Med 2016; 375:12
 When to escalate from nHFT
to other forms of Respiratory
Support
The infant continues to have increased WOB

Increased rates of apnea or bradycardia

An oxygen demand exceeding FiO2 greater than 0.5

to maintain normal SpO2 levels

When respiratory acidosis persists in the absence

of reversible lung disease (pneumothorax)

Clin Perinatol 43 (2016) 693–705

 Weaning Nasal High-flow Therapy

No respiratory distress & adequate lung expansion. Stable for 12 to 24

hours

Tips for weaning from nHFT include wean FiO2 first & then wean flow

rate Weaning in infants with a FiO2 requirement less than 0.3

Wean by 1 L/min every 12 hours, guided by the WOB of the

infant pCO2 values are acceptable

When the flow rate is < 2-3 L/min for 24 hours stop HHHFNC
If the infant still requires O2 consider Low Flow or Incubator O2 otherwise nurse in
Clin Perinatol 43 (2016) 693–705
 Consented guide to the initiation and alteration of NHFT
in neonates

Evidence Support and Guidelines for Using HHHFNC in Neonatology Oxford Nasal High-Flow Therapy Meeting,
2015
Clin Perinatol 43 (2016) 693–
705
 Primary and secondary outcomes

Parental assessment

*Blood gas obtained during routine clinical care within 96 h prior to study enrolment. No additional blood gases were obtained for study purpose.
HHHFNC, heated humidified high flow nasal cannulae; NCPAP, nasal continuous positive airway pressure.

Arch Dis Child Fetal Neonatal Ed 2013;0:F1–F4

 Easier parental
interaction with and
handling of neonates
may be one of the
benefits associated
with HHFNC

Feeding newborns on
HHFNC can be more
easily accomplished
because of the lighter
and less bulky
 Nurses’ experiences by using HHHFNC
to premature infants versus nCPAP
Journal of Neonatal Nursing (2016) 22, 21-6

Neonatal nurses experience HHHFNC as more gentle to the premature baby

than nCPAP, & perceive a dilemma between care & cure when premature infants
are not offered the NIV support that gives them the most satisfaction,
leaves fewer pressure injuries to the face, and
leads to stronger bonding between baby and
parents

Neonatal nurses, in collaboration with

physicians,
have an important task in assessing
when babies can be changed from nCPAP to
HHHFNC`
 High flow nasal cannula for respiratory support in preterm
infants (Review)

 HFNC use has similar rates of efficacy to other forms of non-invasive

respiratory support in preterm infants for preventing treatment failure, death
and CLD.
 Following extubation, use of HFNC is associated with less nasal trauma, and
may be associated with reduced pneumothorax compared with nasal CPAP.
aris.primadi@yahoo.co.id
 Further adequately powered randomized controlled trials should be
undertaken in preterm infants comparing HFNC with other forms of primary
non-invasive support after birth and for weaning from non-invasive support.

Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD006405.

2016
COVID-19 and Neonatal
Respiratory Care Current
Evidence and Practical
Approach

>2 LPM/kg
HFNC

American Journal of Perinatology Vol. 37 No. 8/2020

 ORIGINAL ARTICLE
Exhaled air dispersion and removal is influenced by
isolation room settings during oxygen delivery via nasal
size & ventilation
cannulares
DAVID S. HUI,1,2 BENNY K. CHOW,3 LEO CHU,4 SUSANNA S. NG,2 SIK-TO LAI,5 TONY GIN4 AND MATTHEW T.V. CHAN4

ABSTRACT 1Stanley Ho Center for Emerging Infectious Diseases, Departments of 2Medicine and Therapeutics, 3Architecture and 4Anaesthesia and Intensive Care, The Chinese University
of Hong Kong, and 5Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong, China
Background and objective: We compared the exhaled air dispersion distances during oxygen delivery via
nasal cannula to a human-patient simulator (HPS) in two different isolation rooms.
Methods: Airflow was marked with intrapulmonary smoke for visualization. Oxygen flow was gradually
increased from 1 to 5 L/min, with the HPS sitting at 45°. The leakage jet plume was revealed by laser light-
sheet and images captured by high-definition video. Smoke concentration in the plume was estimated from
the light scattered by smoke particles. The experiments were conducted at a double-door, negative pressure
isolation room with a dimension of 4.1 X 5.1 X 2.6 m, pressure of -7.4 Pa and 16 air exchanges/h (ACH)
(room A). Results were compared with experiments repeated in a smaller isolation room with a dimension of
2.7 X 4.2 X 2.4 pressure of -5Pa and 12 ACH (room B).
m ,
Results: Room A : an exhalation jet spread almost horizontally outward from the nostrils of the HPS to
0.66 m and 1 m towards the end of bed when oxygen flow was increased from 1 to 5 L/min respectively
Room B: there was interaction between the downward ceiling ventilation current and the exhaled .air from the
HPS, leading to deflection of exhaled smoke towards the head of the HPS at an oxygen flow rate of 1 L/min. As
oxygen flow was increased gradually to 5 L/min, more room contamination with smoke was noted.
Conclusions: Substantial exposure to exhaled air occurs within 1 m towards the end of the bed
Exhaled air dispersion distances during application of
from patients receiving oxygen via nasal cannula. Room dimension and air exchange rate are oxygen at 1 L/min (top image), 3 L/min (middle image)
important factors in preventing contamination in isolation rooms. image)
and to the(bottom
5 L/min human-patient simulator with mild lung
the larger
injury in isolation room with more efficient air
espirology (2011) 16, 1005–
exchange.
Advantages and
disadvantages
perceived by surveyed
professionals
Why use HHHFNC ?
• Easy to use
• Safe
• Reduce WOB
• Nurse friendly
• More convenient for the infants
• Reduce nasal trauma
• Reduce pneumothorax
• Reduce “CPAP belly”