Impact of flow and temperature on patient comfort during respiratory support by high-flow nasal cannula

Abstract

Background: The high-flow nasal cannula (HFNC) delivers up to 60 l/min of humidified air/oxygen blend at a temperature close to that of the human body. In this study, we tested whether higher temperature and flow decrease patient comfort. In more severe patients, instead, we hypothesized that higher flow might be associated with improved comfort.

Methods: A prospective, randomized, cross-over study was performed on 40 acute hypoxemic respiratory failure (AHRF) patients (PaO₂/FiO₂ ≤ 300 + pulmonary infiltrates + exclusion of cardiogenic edema) supported by HFNC. The primary outcome was the assessment of patient comfort during HFNC delivery at increasing flow and temperature. Two flows (30 and 60 l/min), each combined with two temperatures (31 and 37 °C), were randomly applied for 20 min (four steps per patient), leaving clinical FiO₂ unchanged. Toward the end of each step, the following were recorded: comfort by Visual Numerical Scale ranging between 1 (extreme discomfort) and 5 (very comfortable), together with respiratory parameters. A subgroup of more severe patients was defined by clinical FiO₂ ≥ 45%.

Results: Patient comfort was reported as significantly higher during steps at the lower temperature (31 °C) in comparison to 37 °C, with the HFNC set at both 30 and 60 l/min (p < 0.0001). Higher flow, however, was not associated with poorer comfort. In the subgroup of patients with clinical FiO₂ ≥ 45%, both lower temperature (31 °C) and higher HFNC flow (60 l/min) led to higher comfort (p < 0.01).

Conclusions: HFNC temperature seems to significantly impact the comfort of AHRF patients: for equal flow, lower temperature could be more comfortable. Higher flow does not decrease patient comfort; at variance, it improves comfort in the more severely hypoxemic patient.

Keywords: Acute hypoxemic respiratory failure; High-flow nasal oxygen; Nursing; Patient comfort; Spontaneous breathing.

Fig. 1

Impact of temperature and flow on patient comfort. Values reported as median with 10°, 25°, 75°, and 90° percentiles as vertical boxes with error bars. a Whole population, overall p < 0.0001 (GLIMMIX). Post hoc analysis: ***p < 0.001 vs HF30-T31, ###p < 0.001 vs HF60-T31. b Subgroup analyses: grey boxes represent FiO₂ < 45% subgroup, while white boxes represent FiO₂ ≥ 45% subgroup. p values from GLIMMIX analysis: treatment effect p < 0.001; FiO₂ effect = 0.055; interaction = 0.035. Post hoc analysis: *p < 0.05 vs HF30-T31; **p < 0.01 vs HF30-T31; ***p < 0.001 vs HF30-T31; #p < 0.05 vs HF60-T31; ##p < 0.01 vs HF60-T31; ###p < 0.001 vs HF60-T31; ††p < 0.01 vs FiO₂ < 45% subgroup (same step). FiO₂ inspired oxygen fraction, HF30-T31 gas flow 30 l/min and temperature 31 °C, HF60-T31 gas flow 60 l/min and temperature 31 °C, HF30-T37 gas flow 30 l/min and temperature 37 °C, HF60-T37 gas flow 60 l/min and temperature 37 °C

Fig. 2

Best and worst comfort. Distribution of “best comfort settings” (a) and “worst comfort settings” (b) expressed as percentage of patients reporting highest or lowest comfort value in that particular study phase (see text for detailed description). HF30-T31 gas flow 30 l/min and temperature 31 °C, HF60-T31 gas flow 60 l/min and temperature 31 °C, HF30-T37 gas flow 30 l/min and temperature 37 °C, HF60-T37 gas flow 60 l/min and temperature 37 °C