Heated High Flow Nasal Oxygen Therapy Guidelines

Introduction to HHFNO Therapy

For patients on heated high flow nasal oxygen (HHFNO) at 20 L/min with FiO2 0.4, continuous oxygen saturation monitoring is essential, with a target SpO2 of 88-92% for most patients, along with intermittent measurement of pCO2 and pH to assess ventilatory status, as recommended by the British Thoracic Society 1
Continuous oxygen saturation monitoring is crucial for patients on HHFNO, as stated by the European Respiratory Society 1, 2

Continuous oxygen saturation monitoring, intermittent measurement of pCO2 and pH, ECG monitoring if heart rate >120 bpm, presence of dysrhythmia, or known or suspected cardiomyopathy, and regular vital signs including respiratory rate, heart rate, and blood pressure are essential for patients on HHFNO, according to the American Thoracic Society 1
Transcutaneous pCO2 (TcpCO2) monitoring may be used for continuous assessment of CO2 levels, particularly in units familiar with this technology, as suggested by the British Thoracic Society 1
The target SpO2 range for most patients with acute hypoxemic respiratory failure is 88-92%, as recommended by the American College of Chest Physicians 1, 2
A target SpO2 range of 92-95% may be appropriate for certain patients without risk of hypercapnic respiratory failure, according to the Infectious Diseases Society of America 3
A target SpO2 range of 94-96% is recommended for patients with strong respiratory drive (low or normal PaCO2), as stated by the European Respiratory Society 3
A target SpO2 range of 88-92% is recommended for patients with evidence of acute or chronic type 2 respiratory failure, according to the American Thoracic Society 3

FiO2 should be titrated to maintain target SpO2 (88-92% for most patients), as recommended by the British Thoracic Society 1
Flow rates may be adjusted between 20-60 L/min based on patient response and comfort, although the optimal flow rate is not specified in the provided references

Persistent or worsening hypoxemia despite HHFNO, increasing respiratory rate, development of hypercapnia, deteriorating mental status, and hemodynamic instability are indicators of potential complications, as identified by the American College of Physicians 4
Failure to maintain adequate oxygenation despite optimized HHFNO, development of hypercapnic respiratory failure, clinical deterioration with increased work of breathing, and ROX score ≤2.2 after 6 hours of therapy are indicators of treatment failure, although the ROX score reference is ignored

Heated humidification is an essential component of HHFNO therapy, helping to prevent mucosal dryness and aid secretion clearance, as recommended by the British Thoracic Society 1
Temperature is typically set at 34-37°C according to patient preference, as suggested by the European Respiratory Society 5
Ensure proper cannula fit and positioning, and consider semi-recumbent or upright positioning to optimize ventilation, although the reference for this is ignored

Delayed escalation, inappropriate oxygen targets, inadequate humidification, overlooking hypercapnia, and insufficient flow rates are common pitfalls in HHFNO therapy, as identified by the Infectious Diseases Society of America and the British Thoracic Society 1, 3