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Review
. 2024 Oct 23;13(21):6350.
doi: 10.3390/jcm13216350.

High-Flow Nasal Oxygen in Patients with Acute Hypercapnic Respiratory Failure: A Narrative Review of the Physiological Rationale and Clinical Evidence

Gabriele Pintaudi  1 , Salvatore Lucio Cutuli  1 , Tommaso Rosà  2 , Teresa Michi  1 , Alessandro Cardu  2 , Filippo Bongiovanni  1 , Massimo Antonelli  1   2 , Domenico Luca Grieco  1   2
Affiliations
Review

High-Flow Nasal Oxygen in Patients with Acute Hypercapnic Respiratory Failure: A Narrative Review of the Physiological Rationale and Clinical Evidence

Gabriele Pintaudi et al. J Clin Med. .

Abstract

Acute hypercapnic respiratory failure is a life-threatening condition caused by alveolar hypoventilation. It is mostly caused by an acute exacerbation of chronic obstructive pulmonary disease or conditions yielding muscle dysfunction. Noninvasive ventilation through a facemask is the cornerstone first-line strategy to support hypercapnic patients with acidemia, and current guidelines strongly recommend this intervention to improve survival and long-term clinical outcomes. Because of its benefits related to carbon dioxide washout from the upper airways and the enhanced comfort, high-flow nasal oxygen has been proposed as a respiratory support strategy in patients with hypercapnic respiratory failure, both as an alternative to and in combination with noninvasive ventilation. When compared to noninvasive ventilation as a first-line intervention, high-flow nasal oxygen shows a higher rate of failure. Hence, if not contraindicated, the use of noninvasive ventilation should be preferred. After the resolution of acidemia with noninvasive ventilation, high-flow nasal oxygen showed promising physiological effects compared to conventional oxygen. During weaning from mechanical ventilation in patients with or at risk of developing hypercapnia, high-flow nasal oxygen showed encouraging results, especially when applied alternating with sessions of noninvasive ventilation. Optimal settings of high-flow nasal oxygen in hypercapnic patients include the use of a smaller-size cannula, flows ranging between 30 and 40 L/min, and FiO2 adjusted to obtain SpO2 between 88% and 92%. Specific interfaces, such as asymmetric cannulas, may further enhance the benefits of a high flow in terms of carbon dioxide clearance. In this narrative review, we provide an updated overview of the physiological rationale and clinical evidence concerning the use of high-flow nasal oxygen in patients with acute hypercapnic respiratory failure.

Keywords: critical care; hypercapnic acidosis; respiratory failure.

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Conflict of interest statement

The authors declare no conflicts of interest.

Figures

Figure 1
Figure 1
Pearls and pitfalls of high-flow nasal oxygen therapy in hypercapnic respiratory failure.
See this image and copyright information in PMC

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