Intensive Care Medicine

, Volume 39, Issue 2, pp 247–257 | Cite as

Use of high flow nasal cannula in critically ill infants, children, and adults: a critical review of the literature

  • Jan Hau LeeEmail author
  • Kyle J. Rehder
  • Lee Williford
  • Ira M. Cheifetz
  • David A. Turner



High flow nasal cannula (HFNC) systems utilize higher gas flow rates than standard nasal cannulae. The use of HFNC as a respiratory support modality is increasing in the infant, pediatric, and adult populations as an alternative to non-invasive positive pressure ventilation.


This critical review aims to: (1) appraise available evidence with regard to the utility of HFNC in neonatal, pediatric, and adult patients; (2) review the physiology of HFNC; (3) describe available HFNC systems (online supplement); and (4) review ongoing and planned trials studying the utility of HFNC in various clinical settings.


Clinical neonatal studies are limited to premature infants. Only a few pediatric studies have examined the use of HFNC, with most focusing on this modality for viral bronchiolitis. In critically ill adults, most studies have focused on acute respiratory parameters and short-term physiologic outcomes with limited investigations focusing on clinical outcomes such as duration of therapy and need for escalation of ventilatory support. Current evidence demonstrates that HFNC generates positive airway pressure in most circumstances; however, the predominant mechanism of action in relieving respiratory distress is not well established.


Current evidence suggests that HFNC is well tolerated and may be feasible in a subset of patients who require ventilatory support with non-invasive ventilation. However, HFNC has not been demonstrated to be equivalent or superior to non-invasive positive pressure ventilation, and further studies are needed to identify clinical indications for HFNC in patients with moderate to severe respiratory distress.


High flow nasal cannula Non-invasive ventilation Gas exchange Hypoxia Respiratory distress Acute lung injury Acute respiratory distress syndrome 


Conflicts of interest

Dr. Cheifetz is a medical advisor to Philips-Respironics and Covidien.

Supplementary material

134_2012_2743_MOESM1_ESM.docx (78 kb)
Supplementary material 1 (DOCX 79 kb)


  1. 1.
    Holleman-Duray D, Kaupie D, Weiss MG (2007) Heated humidified high-flow nasal cannula: use and a neonatal early extubation protocol. J Perinatol 27:776–781PubMedCrossRefGoogle Scholar
  2. 2.
    Spentzas T, Minarik M, Patters AB, Vinson B, Stidham G (2009) Children with respiratory distress treated with high-flow nasal cannula. J Intensive Care Med 24:323–328PubMedCrossRefGoogle Scholar
  3. 3.
    Groves N, Tobin A (2007) High flow nasal oxygen generates positive airway pressure in adult volunteers. Aust Crit Care 20:126–131PubMedCrossRefGoogle Scholar
  4. 4.
    Kallstrom TJ (2002) AARC Clinical Practice Guideline: oxygen therapy for adults in the acute care facility—2002 revision & update. Respir Care 47:717–720PubMedGoogle Scholar
  5. 5.
    Sreenan C, Lemke RP, Hudson-Mason A, Osiovich H (2001) High-flow nasal cannulae in the management of apnea of prematurity: a comparison with conventional nasal continuous positive airway pressure. Pediatrics 107:1081–1083PubMedCrossRefGoogle Scholar
  6. 6.
    Manley BJ, Owen L, Doyle LW, Davis PG (2012) High-flow nasal cannulae and nasal continuous positive airway pressure use in non-tertiary special care nurseries in Australia and New Zealand. J Paediatr Child Health 48:16–21PubMedCrossRefGoogle Scholar
  7. 7.
    Nath P, Ponnusamy V, Willis K, Bissett L, Clarke P (2010) Current practices of high and low flow oxygen therapy and humidification in UK neonatal units. Pediatr Int 52:893–894PubMedCrossRefGoogle Scholar
  8. 8.
    Locke RG, Wolfson MR, Shaffer TH, Rubenstein SD, Greenspan JS (1993) Inadvertent administration of positive end-distending pressure during nasal cannula flow. Pediatrics 91:135–138PubMedGoogle Scholar
  9. 9.
    Wilkinson D, Andersen C, O’Donnell CP, De Paoli AG (2011) High flow nasal cannula for respiratory support in preterm infants. Cochrane Database Syst Rev CD006405Google Scholar
  10. 10.
    Nair G, Karna P (2005) Comparison of the effects of vapotherm and nasal CPAP in respiratory distress. PAS 57:2054.
  11. 11.
    Campbell DM, Shah PS, Shah V, Kelly EN (2006) Nasal continuous positive airway pressure from high flow cannula versus infant flow for preterm infants. J Perinatol 26:546–549PubMedCrossRefGoogle Scholar
  12. 12.
    Miller SM, Dowd SA (2010) High-flow nasal cannula and extubation success in the premature infant: a comparison of two modalities. J Perinatol 30:805–808PubMedCrossRefGoogle Scholar
  13. 13.
    Woodhead DD, Lambert DK, Clark JM, Christensen RD (2006) Comparing two methods of delivering high-flow gas therapy by nasal cannula following endotracheal extubation: a prospective, randomized, masked, crossover trial. J Perinatol 26:481–485PubMedCrossRefGoogle Scholar
  14. 14.
    Abdel-Hady H, Shouman B, Aly H (2011) Early weaning from CPAP to high flow nasal cannula in preterm infants is associated with prolonged oxygen requirement: a randomized controlled trial. Early Human Dev 87:205–208CrossRefGoogle Scholar
  15. 15.
    Saslow JG, Aghai ZH, Nakhla TA, Hart JJ, Lawrysh R, Stahl GE, Pyon KH (2006) Work of breathing using high-flow nasal cannula in preterm infants. J Perinatol 26:476–480PubMedCrossRefGoogle Scholar
  16. 16.
    Shoemaker MT, Pierce MR, Yoder BA, DiGeronimo RJ (2007) High flow nasal cannula versus nasal CPAP for neonatal respiratory disease: a retrospective study. J Perinatol 27:85–91PubMedCrossRefGoogle Scholar
  17. 17.
    DeLay PD, Stone SS, Karzon DT, Katz S, Enders J (1965) Clinical and immune response of alien hosts to inoculation with measles, rinderpest, and canine distemper viruses. Am J Vet Res 26:1359–1373PubMedGoogle Scholar
  18. 18.
    Lampland AL, Plumm B, Meyers PA, Worwa CT, Mammel MC (2009) Observational study of humidified high-flow nasal cannula compared with nasal continuous positive airway pressure. J Pediatr 154:177–182PubMedCrossRefGoogle Scholar
  19. 19.
    Spence KL, Murphy D, Kilian C, McGonigle R, Kilani RA (2007) High-flow nasal cannula as a device to provide continuous positive airway pressure in infants. J Perinatol 27:772–775PubMedCrossRefGoogle Scholar
  20. 20.
    McKiernan C, Chua LC, Visintainer PF, Allen H (2010) High flow nasal cannulae therapy in infants with bronchiolitis. J Pediatr 156:634–638PubMedCrossRefGoogle Scholar
  21. 21.
    Schibler A, Pham TM, Dunster KR, Foster K, Barlow A, Gibbons K, Hough JL (2011) Reduced intubation rates for infants after introduction of high-flow nasal prong oxygen delivery. Intensive Care Med 37:847–852PubMedCrossRefGoogle Scholar
  22. 22.
    Kim IK, Phrampus E, Sikes K, Pendleton J, Saville A, Corcoran T, Gracely E, Venkataraman S (2011) Helium–oxygen therapy for infants with bronchiolitis: a randomized controlled trial. Arch Pediatr Adolesc Med 165:1115–1122PubMedCrossRefGoogle Scholar
  23. 23.
    Kim IK, Phrampus E, Venkataraman S, Pitetti R, Saville A, Corcoran T, Gracely E, Funt N, Thompson A (2005) Helium/oxygen-driven albuterol nebulization in the treatment of children with moderate to severe asthma exacerbations: a randomized, controlled trial. Pediatrics 116:1127–1133PubMedCrossRefGoogle Scholar
  24. 24.
    Dewan NA, Bell CW (1994) Effect of low flow and high flow oxygen delivery on exercise tolerance and sensation of dyspnea. A study comparing the transtracheal catheter and nasal prongs. Chest 105:1061–1065PubMedCrossRefGoogle Scholar
  25. 25.
    Chatila W, Nugent T, Vance G, Gaughan J, Criner GJ (2004) The effects of high-flow vs low-flow oxygen on exercise in advanced obstructive airways disease. Chest 126:1108–1115PubMedCrossRefGoogle Scholar
  26. 26.
    Kernick J, Magarey J (2010) What is the evidence for the use of high flow nasal cannula oxygen in adult patients admitted to critical care units? A systematic review. Aust Crit Care 23:53–70PubMedCrossRefGoogle Scholar
  27. 27.
    Roca O, Riera J, Torres F, Masclans JR (2010) High-flow oxygen therapy in acute respiratory failure. Respir Care 55:408–413PubMedGoogle Scholar
  28. 28.
    Tiruvoipati R, Lewis D, Haji K, Botha J (2010) High-flow nasal oxygen vs high-flow face mask: a randomized crossover trial in extubated patients. J Crit Care 25:463–468PubMedCrossRefGoogle Scholar
  29. 29.
    Parke RL, McGuinness SP, Eccleston ML (2011) A preliminary randomized controlled trial to assess effectiveness of nasal high-flow oxygen in intensive care patients. Respir Care 56:265–270PubMedCrossRefGoogle Scholar
  30. 30.
    Sztrymf B, Messika J, Mayot T, Lenglet H, Dreyfuss D, Ricard JD (2011) Impact of high-flow nasal cannula oxygen therapy on intensive care unit patients with acute respiratory failure: a prospective observational study. J Crit Care 27(3):324.e9–324.e13Google Scholar
  31. 31.
    Sztrymf B, Messika J, Bertrand F, Hurel D, Leon R, Dreyfuss D, Ricard JD (2011) Beneficial effects of humidified high flow nasal oxygen in critical care patients: a prospective pilot study. Intensive Care Med 37:1780–1786PubMedCrossRefGoogle Scholar
  32. 32.
    Parke RL, McGuinness SP, Dixon R, Jull A (2012) Protocol for a randomised controlled trial of nasal high flow oxygen therapy compared to standard care in patients following cardiac surgery: the HOT-AS study. Int J Nurs Stud 49(3):338–344PubMedCrossRefGoogle Scholar
  33. 33.
    Corley A, Caruana LR, Barnett AG, Tronstad O, Fraser JF (2011) Oxygen delivery through high-flow nasal cannulae increase end-expiratory lung volume and reduce respiratory rate in post-cardiac surgical patients. Br J Anaesth 107:998–1004PubMedCrossRefGoogle Scholar
  34. 34.
    Lenglet H, Sztrymf B, Leroy C, Brun P, Dreyfuss D, Ricard JD (2012) Humidified high flow nasal oxygen during respiratory failure in the emergency department: feasibility and efficacy. Respir care 57(11):1873–1878Google Scholar
  35. 35.
    Antonelli M, Conti G, Moro ML, Esquinas A, Gonzalez-Diaz G, Confalonieri M, Pelaia P, Principi T, Gregoretti C, Beltrame F, Pennisi MA, Arcangeli A, Proietti R, Passariello M, Meduri GU (2001) Predictors of failure of noninvasive positive pressure ventilation in patients with acute hypoxemic respiratory failure: a multi-center study. Intensive Care Med 27:1718–1728PubMedCrossRefGoogle Scholar
  36. 36.
    Esteban A, Frutos-Vivar F, Ferguson ND, Arabi Y, Apezteguia C, Gonzalez M, Epstein SK, Hill NS, Nava S, Soares MA, D’Empaire G, Alia I, Anzueto A (2004) Noninvasive positive-pressure ventilation for respiratory failure after extubation. N Engl J Med 350:2452–2460PubMedCrossRefGoogle Scholar
  37. 37.
    Antonelli M, Conti G, Esquinas A, Montini L, Maggiore SM, Bello G, Rocco M, Maviglia R, Pennisi MA, Gonzalez-Diaz G, Meduri GU (2007) A multiple-center survey on the use in clinical practice of noninvasive ventilation as a first-line intervention for acute respiratory distress syndrome. Crit Care Med 35:18–25PubMedCrossRefGoogle Scholar
  38. 38.
    Huang J, Fridman D (2011) High flow oxygen and low dose inhaled nitric oxide in a case of severe pulmonary hypertension and obstructive shock. Chest 140(4_Meeting Abstracts):63AGoogle Scholar
  39. 39.
    Boyer A, Vargas F, Delacre M, Saint-Leger M, Clouzeau B, Hilbert G, Gruson D (2011) Prognostic impact of high-flow nasal cannula oxygen supply in an ICU patient with pulmonary fibrosis complicated by acute respiratory failure. Intensive Care Med 37:558–559PubMedCrossRefGoogle Scholar
  40. 40.
    Atwood C, Miller T, McMillan N, Hartwig K, Camhi S, Schweikert H (2011) Effect of high flow highly humidified air via nasal cannula on respiratory effort in patients with advanced COPD. Chest 140(4_Meeting Abstracts):536AGoogle Scholar
  41. 41.
    Carratala Perales JM, Llorens P, Brouzet B, Albert Jimenez AR, Fernandez-Canadas JM, Carbajosa Dalmau J, Martinez Beloqui E, Ramos Forner S (2011) High-flow therapy via nasal cannula in acute heart failure. Rev Esp Cardiol 64:723–725PubMedCrossRefGoogle Scholar
  42. 42.
    McGinley BM, Patil SP, Kirkness JP, Smith PL, Schwartz AR, Schneider H (2007) A nasal cannula can be used to treat obstructive sleep apnea. Am J Respir Crit Care Med 176:194–200PubMedCrossRefGoogle Scholar
  43. 43.
    Calvano TP, Sill JM, Kemp KR, Chung KK (2008) Use of a high-flow oxygen delivery system in a critically ill patient with dementia. Respir Care 53:1739–1743PubMedGoogle Scholar
  44. 44.
    Epstein AS, Hartridge-Lambert SK, Ramaker JS, Voigt LP, Portlock CS (2011) Humidified high-flow nasal oxygen utilization in patients with cancer at Memorial Sloan-Kettering Cancer Center. J Palliat Med 14:835–839PubMedCrossRefGoogle Scholar
  45. 45.
    Wettstein RB, Shelledy DC, Peters JI (2005) Delivered oxygen concentrations using low-flow and high-flow nasal cannulas. Respir Care 50:604–609PubMedGoogle Scholar
  46. 46.
    Wagstaff TA, Soni N (2007) Performance of six types of oxygen delivery devices at varying respiratory rates. Anaesthesia 62:492–503PubMedCrossRefGoogle Scholar
  47. 47.
    Ritchie JE, Williams AB, Gerard C, Hockey H (2011) Evaluation of a humidified nasal high-flow oxygen system, using oxygraphy, capnography and measurement of upper airway pressures. Anaesth Intensive Care 39:1103–1110PubMedGoogle Scholar
  48. 48.
    Frizzola M, Miller TL, Rodriguez ME, Zhu Y, Rojas J, Hesek A, Stump A, Shaffer TH, Dysart K (2011) High-flow nasal cannula: impact on oxygenation and ventilation in an acute lung injury model. Pediatr Pulmonol 46:67–74PubMedCrossRefGoogle Scholar
  49. 49.
    Danan C, Dassieu G, Janaud JC, Brochard L (1996) Efficacy of dead-space washout in mechanically ventilated premature newborns. Am J Respir Crit Care Med 153:1571–1576PubMedGoogle Scholar
  50. 50.
    Dassieu G, Brochard L, Agudze E, Patkai J, Janaud JC, Danan C (1998) Continuous tracheal gas insufflation enables a volume reduction strategy in hyaline membrane disease: technical aspects and clinical results. Intensive Care Med 24:1076–1082PubMedCrossRefGoogle Scholar
  51. 51.
    Miller MJ, DiFiore JM, Strohl KP, Martin RJ (1990) Effects of nasal CPAP on supraglottic and total pulmonary resistance in preterm infants. J Appl Physiol 68:141–146PubMedGoogle Scholar
  52. 52.
    Dysart K, Miller TL, Wolfson MR, Shaffer TH (2009) Research in high flow therapy: mechanisms of action. Respir Med 103:1400–1405PubMedCrossRefGoogle Scholar
  53. 53.
    Kubicka ZJ, Limauro J, Darnall RA (2008) Heated, humidified high-flow nasal cannula therapy: yet another way to deliver continuous positive airway pressure? Pediatrics 121:82–88PubMedCrossRefGoogle Scholar
  54. 54.
    Parke R, McGuinness S, Eccleston M (2009) Nasal high-flow therapy delivers low level positive airway pressure. Br J Anaesth 103:886–890PubMedCrossRefGoogle Scholar
  55. 55.
    Urbano J, Castillo JD, Lopez-Herce J, Gallardo JA, Solana MJ, Carrillo A (2012) High-flow oxygen therapy: pressure analysis in a pediatric airway model. Respir Care 57(5):721–726PubMedCrossRefGoogle Scholar
  56. 56.
    Hasan RA, Habib RH (2011) Effects of flow rate and airleak at the nares and mouth opening on positive distending pressure delivery using commercially available high-flow nasal cannula systems: a lung model study. Pediatr Crit Care Med 12:e29–e33PubMedCrossRefGoogle Scholar
  57. 57.
    Volsko TA, Fedor K, Amadei J, Chatburn RL (2011) High flow through a nasal cannula and CPAP effect in a simulated infant model. Respir Care 56:1893–1900PubMedCrossRefGoogle Scholar
  58. 58.
    United States National Institutes of Health (1993)
  59. 59.
    Australian New Zealand Clinical Trials Registry (2007).
  60. 60.
    World Health Organization (2012) International Clinical Trials Registry Platform (ICTRP) Search Portal.

Copyright information

© Springer-Verlag Berlin Heidelberg and ESICM 2012

Authors and Affiliations

  • Jan Hau Lee
    • 1
    • 2
    • 3
    Email author
  • Kyle J. Rehder
    • 1
  • Lee Williford
    • 4
  • Ira M. Cheifetz
    • 1
    • 4
  • David A. Turner
    • 1
  1. 1.Division of Pediatric Critical Care Medicine, Department of PediatricsDuke Children’s HospitalDurhamUSA
  2. 2.Duke Clinical Research InstituteDurhamUSA
  3. 3.Children’s Intensive Care Unit, Department of Pediatric SubspecialtiesKK Women’s and Children’s HospitalSingaporeSingapore
  4. 4.Department of Respiratory Care ServicesDuke University Medical CenterDurhamUSA

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