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Contents lists available at ScienceDirect

Australian Critical Care

journal homepage: www.elsevier.com/locate/aucc

Research paper

Nasal high-ow oxygen therapy in ICU: A before-and-after study

Nigel Fealy RN, MN, ICU Cert, Grad Dip Ed, ACCCN a,b,c, ,
Claire Osborne RN, ICU Cert a ,
Glenn M. Eastwood RN, PhD, GradDip Crit Care, ACCCN a,c ,
Neil Glassford MBChB, MRCP a,d ,
Graeme Hart MD, FCICM, FANZCA, FACHI a ,
Rinaldo Bellomo MD, FRACP, FCICM a,d
a

Department of Intensive Care, Austin Hospital, Melbourne Australia

School of Nursing and Midwifery, Grifth University, Brisbane Australia
c
School of Nursing and Midwifery, Deakin University, Melbourne, Australia
d
Australian and New Zealand Intensive Care Research Centre (ANZICS-RC), School of Preventative Medicine and Public Health, Monash University,
Melbourne, Australia
b

article information
Article history:
Received 24 November 2014
Received in revised form 26 March 2015
Accepted 18 May 2015
Available online xxx
Keywords:
Oxygen therapy
Intensive care nasal high-ow
Nasal prongs
Nasal cannulae
Acute nursing care
Critical illness

a b s t r a c t
Background: Non-intubated intensive care patients commonly receive supplemental oxygen by high-ow
face mask (HFFM), simple face mask (FM) and nasal prongs (NP) during their ICU admission. However,
high-ow nasal prongs (HFNP) offer considerable performance capabilities that may sufciently meet all
their oxygen therapy requirements.
Study aims: To assess the feasibility, safety and cost-effectiveness of introducing a protocol in which HFNP
was the primary oxygen delivery device for non-intubated intensive care patients.
Method: Prospective 4-week before-and-after study (6 months apart) for all adult patients admitted to a
22-bed tertiary ICU in Melbourne, Australia.
Results: 117 patients (57 before, 60 after) were included: 86 (73.5%) received mechanical ventilation.
Feasibility revealed a signicant reduction in HFFM (52.60%, p < .001), FM (35.18.3%, p = .002) and NP
(75.436.7%, p < .001) use and an increase in HFNP use (31.681.7%, p < .05) during the after period. Following extubation, there was a signicant reduction in HFFM use (65.7% vs. 0%, p < .05) and an increase
HFNP use (8.6% vs. 87.5%, p < .05). Costing was in favour of the after period with a consumable cost saving per patient (AUD $32.56 vs. $17.62, p < .05). During the after period, more patients were discharged
from ICU with HFNP than during the before period (5 vs. 33 patients, p < .05) and fewer patients (5 vs.
14 patients) used three or more oxygen delivery devices. Safety outcomes demonstrated no signicant
difference in the number of intubations, re-intubations, readmissions or non-invasive ventilation use
between the two time periods.
Conclusions: Using HFNP as the primary oxygen delivery method for non-intubated intensive care patients
was feasible, appeared safe, and the oxygen device costs were reduced. The ndings of our single-centre
study support further multi-centre evaluations of HFNP therapy protocols in non-ventilated intensive
care patients.
2015 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.

1. Introduction
Intensive care patients commonly receive supplemental oxygen therapy during their intensive care unit (ICU) admission.13

Corresponding author at: Department of Intensive Care, Austin Hospital, Studley

Road, Heidelberg, VIC 3084, Australia. Tel.: +61 3 94964834; fax: +61 3 94963932.
E-mail address: nigel.fealy@austin.org.au (N. Fealy).

For non-intubated intensive care patients, nasal prongs (NP) and

face mask (FM) oxygen delivery devices are commonly used. Benets of these devices include adequate humidication of the upper
airway and the ability to more precisely control the fraction of
inspired oxygen (FiO2 ).4 Two high-ow oxygen delivery devices
are the high-ow face mask (HFFM) and high-ow nasal prongs
(HFNP).
High-ow oxygen therapy devices are used in clinical practice
in order to deliver an oxygen ow rate exceeding the patients

http://dx.doi.org/10.1016/j.aucc.2015.05.003
1036-7314/ 2015 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.

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inspiratory ow rate. By exceeding the patients inspiratory ow

rate, high-ow oxygen delivery devices are able to deliver a more
precisely known fraction of inspired oxygen (FiO2 ).4 Delivering
higher oxygen ow rates can dry the patients upper airway, cause
discomfort and may result in the patient removing the device
and being exposed to unnecessary hypoxaemia. To enhance the
comfort and efcacy of this form of oxygen therapy, humidiers
are used in conjunction with high-ow oxygen devices. However, HFNP therapy in contrast to HFFM allows patients to eat
and drink more easily. To date most studies examining the use
of HFNP have been conducted for or with patients with respiratory failure, post-cardiac surgery and during palliative care. There
has not yet been a pragmatic examination of HFNP in the ICU
setting.5,712
Accordingly, we examined the introduction of a HFNP protocol in a tertiary ICU that sought to provide a uniform approach
to supplemental oxygen therapy for non-ventilated intensive care
patients. We hypothesised that the HFNP protocol would be; feasible in terms of increasing HFNP use and reducing other oxygen
device use; safe in relation to intubation and re-intubation rates,
non-invasive ventilatory (NIV) requirements and ICU length of stay,
readmission to the ICU; and cost-effective in reducing the number
of oxygen delivery devices used per-patient.

2. Methods
2.1. Study design and setting
We performed a prospective 4 week before-and-after pilot
study (6 months apart) in December, 2012 and May, 2013. This
study was conducted at the Austin Hospital, a tertiary academic
hospital admitting approximately of 65,000 patients each year.
From January 2012 to December 2013, 4260 critically ill patients
were admitted to our 22-bed general medical-surgical ICU. During
the study there were 220 nurses lling 134 full-time-equivalent
positions. All patients admitted to the ICU over the study period
(November 2012 and May 2013) were included in our analysis.
In the before period, oxygen delivery and oxygen management decisions were jointly performed by the bedside nurses and
treating doctors. During this period the available oxygen delivery devices included nasal prongs, simple face masks, high-ow
face mask and HFNP. In our unit there was no protocol regarding
oxygen delivery device use at different stages of oxygen therapy
requirements.
Throughout December 2012, a comprehensive education programme lead by the ICU nurse educators, involving formal lectures,
informal bedside teaching, and feedback was performed to introduce a new protocol for the use of HFNP therapy. In-service lectures
were performed to provide nursing staff with background information on oxygen delivery in ICU, the rationale supporting the
introduction of HFNP and practical information about HFNP use. At
the bedside we used the Optiow, MR 850 (Fisher & Paykel Healthcare, Auckland, New Zealand) to provide HFNP therapy. For HFNP
therapy, the humidier water chamber temperature was set at
37 C to deliver 44 mg H2 O/L. Bedside teaching sessions, performed
by the ICU educators, supported the formal in-service lectures and
provided the ability to troubleshoot any problems associated with
HFNP use.
Where possible, HFNP therapy utilised the existing regulated
humidication system from the ventilator set-up. In each instance
nurses were instructed to set initial therapy to FiO2 0.4 and a ow
rate of 40 L/min. Subsequent alterations in FiO2 or L/min were at
the bedside nurses discretion. The HFNP protocol was uploaded to
the ICU intranet website and a physical copy made available at each
patient bed space. The protocol was embedded in ICU practice over

a six-month period. After period data were collected for patients

admitted to the ICU during May 2013.
2.2. Data collection and management
Using a purpose developed case report form, we collected demographic information for age, gender, type of admission and Acute
Physiology and Chronic Health Evaluation (APACHE) III scores.
Feasibility outcome variables for oxygen therapy related information (duration and type of oxygen delivery device use (excluding
mechanical ventilation), the presence of humidication, recorded
FiO2 and L/min were also recorded. Safety measurements included
outcome information (ICU length of stay, requirement for NIV and
NIV hours, incidence of intubation and re-intubation and ICU readmission). Cost of oxygen therapy was calculated as the median cost
per device multiplied by the number of oxygen devices used on
a per patient basis, excluding ventilator circuits and allowing for
patients to use each device more than once during their admission.
All study related information was additionally retrieved via a retrospective medical record audit and via an electronic database search
for illness severity and outcome data.
2.3. Data analysis
Data were analysed using a commercially available statistics
package (Statview, Abacus, CA.). Continuous data are presented
as median and interquartile range (25th75th percentiles) and
dichotomous data are presented as percentages. Groups were compared using the Mann Whitney U test or Fishers exact test as
appropriate. A p-value < .05 was used to indicate statistical signicance.
2.4. Ethical considerations
The Austin Health Human Research Ethics Committee approved
our study (H2011/04434), including a waiver of consent.
3. Results
3.1. Patient characteristics
During the study period, there were a total of 117 patients
admitted to the ICU: 57 patients in the before period and 60 patients
in the after period. The two groups had similar baseline characteristics with respect to age and gender. There was, however, a
statistically signicant difference between the groups in relation to
the number of patients admitted to the unit following liver transplantation. There was no difference in median ICU or hospital length
of stay between groups (Table 1). Of the 117 patients admitted, 86
(73.5%) received mechanical ventilation during their ICU admission. More patients were ventilated during the after period of the
study: 36 (63.2%) vs. 50 (83.3%) (p = .02). However, median duration
of ventilation was similar for the before and after periods, 13 h (IQR
756 h) vs. 16 h (IQR 1790 h) (p = .69) respectively (Table 1).
3.2. Oxygen delivery and oxygen delivery device use
Of the 86 patients mechanically ventilated during their ICU
admission, 83 patients were extubated to spontaneously breathing
oxygen devices. One patient in the before period and two patients in
the after period died without being extubated. Of these 83 patients,
35 in the before period and 48 in the after period proceeded to
extubation. For those participants extubated in the ICU, there was
a signicant decrease in patient HFFM oxygen device use immediately post-extubation in the after period group (65.7% vs. 0%,
p < .001). The corresponding application of HFNP immediately post

Please cite this article in press as: Fealy N, et al. Nasal high-ow oxygen therapy in ICU: A before-and-after study. Aust Crit Care (2015),
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Table 1
Baseline patient characteristics.

Table 2
Spontaneous breathing O2 delivery device use during ICU stay.

Characteristic

Pre n = 57

Post n = 60

Age (yrs) median

(IQR)
Male (%)
Cardiac surgery
Cardiology
Respiratory
Gastrointestinal
Neurosurgery
Neurology
Liver
transplantation
Ortho
Overdose
Severity of illness
scores
APACHE III
(median + IQR)
Length of stay
Total ICU LOS (h)
ICU h
(median + IQR)
Hospital (Days)
(median + IQR)
Mechanical
ventilation
No. of patients
Total mechanical
vent (h)
MV hours
(median + IQR)

61.21 (51.574.5)

61.27 (5271)

p-Value

27 (47.4%)
16 (28.1%)
7 (12.3%)
13 (22.8%)
12 (21.1%)
1 (1.8%)
2 (3.5%)
0 (0%)

38 (63.3%)
15 (25%)
6 (10%)
13 (21.7%)
9 (15%)
4 (6.7%)
5 (8.3%)
8 (13.3%)

2 (3.4%)
4 (7%)

0 (0%)
0 (0%)

58 (4378)

60 (4674)

3935
39 (21.574.25)

6000.5
44.25 (20.25143.25)

.44

8.69 (6.0819.9)

10.94 (7.4820.99)

.15

.60
.09
.83
.77
1.00
.47
.36
.44
.006
.23
.053

1.00

36 (63.2%)
1250.5

50 (83.3%)
3291

.02

13 (7.6256.25)

16 (16.6290.25)

.69

APACHE: Acute Physiology Chronic Health Evaluation.

extubation was signicantly higher in the after period (8.6% vs.

87.5% of patients, p < .001); demonstrating a 14 fold increase.
For those patients not intubated and for the remainder of the
patients, during their time in ICU following extubation, there was
a signicant decrease in the patient use of HFFM (52.6% vs. 0%,
p < .001), NP (75.4% vs. 36.7%, p < .001) and FM (35.1% vs. 8.3%,
p = .002) oxygen delivery devices in the after period compared with
the before period. Correspondingly, there was a signicant increase
in the number of patients utilising HFNP in the after period (31.6%
vs. 81.7%, p < .001), as well as an increase in total estimated hours
of use (781.5 vs. 1841 h) (Table 2).
Fifty-two of 57 patients (91.2%) in the before period and 55 of
60 patients (91.7%) in the after period were discharged from ICU
alive. At ICU discharge during the before period, there was a significant reduction in patients being discharged on HFFM (14% vs. 0%
patients, p = .002) and NP (54.4% vs. 15% of patients p < .001). There
was a signicant increase in the number of patients discharged on
HFNP (8.8% vs. 55% of patients, p < .001). The median discharge FiO2
was essentially the same for both groups [FiO2 0.27 in the before
period [(FiO2 IQR 0.250.3)] and 0.3 in the after period (FiO2 IQR
0.220.4)]. To coincide with the increase in HFNP use, there was an
expected increase in the median ow in L/min in the after (20 L/min,
IQR 0.7520 L/min) compared to the before period (3 L/min, IQR
212)(p = .29) (Table 3).
The requirement for intubation and reintubation the ICU were
the same for both periods, as well as the number of patients readmitted to the ICU post discharge. The number of patients requiring
non-invasive ventilation (NIV) was also similar for both periods
(26.3% vs. 21.7% patients, p = .52) as well as the median NIV hours:
21 h pre-intervention period (IQR 1232 h) vs. 18 h in the after
period (IQR 524 h, p = .31). There was a 14-fold increase in the use
of regulated humidier systems during the after period (8.6% vs.
87.5% patients, p < .001) (Table 3).

High ow face mask

No of patients
Total hours
Hours of use
(median + IQR)
FiO2 (median + IQR)
Flow (median + IQR)
42 (4242)
0
High ow nasal prongs
No of patients
Total hours
Hours of use
(median + IQR)
FiO2 (median + IQR)
Flow (median + IQR)
35 (2040)
30 (2040)
.38
Simple face mask
No of patients
Total hours
Hours of use
(median + IQR)
FiO2 (median + IQR)
Flow (median + IQR)
8 (610)
6 (5.510)
.62
Simple nasal prongs
No of patients
Total hours
Hours of use
(median + IQR)
FiO2 (median + IQR)
Flow (median + IQR)
3 (34)
3 (23.25)
.27
Room air
No of patients
Total hours
Hours of use
(median + IQR)
Non invasive ventilation
No of patients
Total hours
Hours of use
(median + IQR)
FiO2 (median + IQR)
Total Spontaneous device
hours

Pre n = 57

Post n = 60

p-Value

30 (52.6%)
254
7 (2.8710)

0 (0%)
0
0

<.001

49 (81.7%)
1841
16 (6.552.25)

<.001

0.4 (0.40.5)
0

18 (31.6%)
781.5
29 (15.7569)

.23

0.4 (0.40.5)
0.4 (0.40.4)
.31

20 (35.1%)
113
3 (1.127.5)

5 (8.3%)
9
1 (11.75)

.002
.23

0.375 (0.350.475)
0.4 (0.350.45)
.76

43 (75.4%)
809
13 (527)

22 (36.7%)
368.5
11.5 (4.527.5)

<.001
.67

0.27 (0.273.0)
0.27 (0.250.28)
.27

17 (29.8%)
401
9.5 (0.7515.75)

23 (38.3)
226
8.0 (214)

.43

15 (26.3%)
326
21 (12.2532.37)

13 (21.7%)
265
18 (5.524.5)

.52

0.6 (0.50.6)
2684.5

0.4 (0.40.45)
2709.5

<.05

.85

.31

3.3. Costs associated with oxygen delivery device use

In the after period group there was an increase in the number of patients that received two or three oxygen delivery devices
per patient admission (29 vs. 46 patients), with a reduction in the
number of patients utilising three or more devices throughout the
admission period (14 vs. 5 patients) (Table 3). This change in device
use was associated with a reduction in cost for oxygen delivery
devices between the two periods. This is illustrated in Table 3 where
57 patients utilised a total of 111 oxygen delivery devices during
the before period with a combined cost of consumables (HFFM kit,
NP, FM and HFNP, oxygen tubing) of $1336.72. In the after period,
60 patients utilised a total of 76 oxygen delivery devices with a consumable price of $879.92 for the comparable time period. There was
a signicant reduction in median device cost per patient from the
before period [AUD $32.56 ($ IQR 0.5234.1)] compared to the after
period [AUD $17.62 ($ IQR 17.6218.14), p = .008].

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Table 3
Humidication, oxygen delivery device use, cost and interventions.
Humidication device
on extubation

Pre n = 35

None
8 (22.9%)
32 (91.4%)
None regulated heater
humidier
3 (8.6%)
Regulated heater
humidier
Amount of O2 devices used during ICU stay
14
1 device
29
23 devices
14
>3 devices
111
Total devices
Total device cost
$1336.72
$32.56
Device cost per patient
(0.5234.10)
stay (median + IQR)
Patient deterioration
8
Intubation in the ICU
4 (3.4%)
Readmission to ICU
1 (0.9%)
Reintubation in the
ICU
Discharge parameters
0.27 (0.250.3)
FiO2 (median + IQR)
Flow (median + IQR)

3 (212.25)

Post n = 48

p-Value

7 (14.6%)
0 (0)

.786
<.001

42 (87.5%)

<.001

9
46
5
76
$879.92
$17.62
(17.6218.14)
7
5 (4.3%)
2 (1.7%)

0.3
(0.220.4)
20 (0.7520)

.008

1.00
1.00
1.00

.16
.29

4. Discussion
4.1. Key ndings
In our prospective, before-and-after observational study for the
introduction of a HFNP protocol we report four key ndings. First,
the introduction of a targeted clinical protocol induced a signicant
change to HFNP therapy overall and during the immediate postextubation period. This nding is interesting as the study was done
non-intrusively in order to avoid complications of the Hawthorne
effect. Since the application of oxygen therapy is one of many therapies a nurse in the ICU provides, a study under close observation is
likely to improve performance and adherence to a protocol. Apart
from the training to use the protocol, the ICU nurses were unaware
of the research associated. For the same reason the analysis of oxygen device data was performed 6 months after the introduction and
implementation of the protocol. This could therefore be seen as an
indirect measure of device acceptance and the protocol for oxygen
administration. Second, HFNP therapy did not alter the incidence
of respiratory adverse events. The incidence of intubation without prior mechanical ventilation, re-intubation, NIV requirements,
hours of NIV use and readmission to the ICU were comparable for
the two time periods. While this nding may indicate efcacy of
HFNP as an alternative device therapy in this group of patients,
we believe a larger sample size is required to further clarify these
issues. Third, the majority of intensive care patients who received
HFNP did so in association with a regulated active humidication
system. Adequate humidication while receiving oxygen via a highow device appears desirable as the drying effect of oxygen may
impact on patient compliance with therapy. Fourth, the increased
use of HFNP as the primary oxygen delivery device led to a reduction in cost of oxygen therapy consumables per ICU admission and
for the hospital.
4.2. Relationship with previous ndings
Despite supplemental oxygen being widely prescribed therapeutic drug in medicine,13 there remains little published evidence
to guide intensive clinicians on selecting the most appropriate
oxygen delivery device in non-intubated patients.1 Indeed, much
variability in the management of oxygen therapy and delivery
devices in critical and non-critical care settings has been identied

previously.1,2,1417 A recent point prevalence study of 506 patients

from 40 Australian and New Zealand ICUs reported that 35.2% of
patients were non-intubated and receiving supplemental oxygen
therapy.3 The majority of patients were receiving oxygen therapy
via NP (65.7%). Few patients received supplemental oxygen by FM
(5.6%), HFFM (2.8%) or HFNP (18.5%). In contrast our results indicate a substantial pre-intervention use of HFFM (52.6%), FM (35.1%)
and HFNP (31.6%) while in ICU. However, the previous study was a
point of prevalence audit, which was unable to capture all utilised
oxygen delivery devices or the use of multiple devices whereas our
study included all devices used during ICU admission.
Parke et al. reported that 75.6% of patients were receiving
oxygen therapy without any medical policy or prescription of
device, FiO2 and ow. This is consistent with our pre-intervention
practice where nurses independently prescribed both device and
oxygen settings. Eastwood et al.18 , in aiming to establish critical
care nurses opinions regarding oxygen therapy practices, reported
nurses having a signicant inuence on oxygen delivery device,
with 33.1% indicating an absence of delivery device protocols in
their intensive care units.
The initiation of a clinical oxygen therapy policy in this study
aimed to institute use of HFNP as the preferred choice of oxygen delivery device, spanning their pathway from admission or
post-extubation, to ICU discharge. Limited literature addressing the
use of HFNP to prevent or treat post extubation respiratory failure
exists. Moccaldo and colleagues randomised 109 patients to receive
either HFFM via venturi air entrainment devices or HFNP,19 reporting a signicant decrease in re-intubation rates in favour of the
HFNP group (3.5%) compared to the high ow venturi group (21%)
in a setting with high rates of reintubation. We report markedly
lower re-intubation rates and did not demonstrate any signicant
difference in re-intubation rates post-intervention (0.9% vs. 1.7%,
p = 1.00).
In a small study addressing physiological outcomes, the efcacy of HFNP and HFFM in 50 extubated patients were compared.9
All patients were extubated to HFFM (30 L/min) and, if stable
after 30 min, were then randomised to either crossover protocol;
A = HFFM (30 L/min) followed by HFNP (30 L/min) or B = HFNP followed by HFFM, with 30-min intervals for each device. There was
no difference in outcomes for PaO2 , CO2 , oxygen saturation, respiratory rate, heart rate or blood pressure. There was however, a
signicant difference in terms of device tolerance utilising a visual
analogue scale, where a score of 1 indicates full compliance and
5 noncompliance in favour of HFNP (0.2 vs. 0.66, p = .01). Rittayamai and colleagues20 conducted a similar crossover study (n = 17)
patients where patients were randomised after extubation to protocol A = HFNP (35 L/min) 30 min followed by rebreather mask
(610 L/min), or protocol B = rebreather mask 30 min followed by
HFNP. In this study, patients extubated to HFNP demonstrated less
dyspnoea (1.6 vs. 2.9, p = .04), lower respiratory rate (19.8 vs. 23.1,
p = .009) and heart rate (89.5 vs. 95.4, p = .006).
The most recent study to assess the efcacy of HFNP vs. conventional oxygen therapy was a randomised controlled trial conducted
in 340 post operative cardiac surgical patients.21 Conventional oxygen therapy was classied as NP and FM at 24 L/min whereas
HFNP was delivered at a ow rate of 45 L/min. In this particular
study there was no difference in oxygen levels in either group.
There was however, a reported reduction in the requirement for
escalation of respiratory support for impaired oxygenation (higher
oxygen ow rates, change of device) in favour of HFNP (35 vs. 11,
p = .001).
Other published evaluations of HFNP have largely targeted specic groups such as those diagnosed with hypoxaemic respiratory
failure or post operative cardiac surgical patients.2224 Price and
colleagues conducted a 2-year retrospective audit of 72 post operative surgical patients with a diagnoses of type I respiratory failure.22

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While this study aimed to assess the performance and acceptance of

the technology, they noted some improvement in PaO2 , SpO2 , and
respiratory rate. In 2010, Roca and colleagues7 described the impact
of HFNP at 30 L/min in 20 patients identied with hypoxaemic
respiratory failure compared to NP and FM limited to 15 L/min.
Patients responded favourably to HFNP with statistically signicant
improvement in PaO2 (mmHg) (77 vs. 127, p = .002) and respiratory
rate (28 vs. 21, p < .001).
In 2011, Parke and colleagues24 conducted a randomised comparative study aimed at examining the effectiveness of HFNP in 60
patients diagnosed with mild to moderate hypoxaemic respiratory
failure in a cardiothoracic and vascular ICU. In this study, patients
were randomised to high ow face mask or HFNP (35 L/min) with
the requirement for NIV one of the main outcomes. The rate of
NIV in the HFFM group was higher than that of the HFNP group
[8/27 (30%) vs. 3/29 (10%), p = .10]. In addition, more patients using
HFNP [26/29 (89.7%)], were deemed to have succeeded in their
therapy compared to HFFM [15/27 (55.6%), p = .006], where failure
was dened as worsening respiratory failure requiring a change
in respiratory support device, within 24 h of enrolment. Of the 12
patients deemed to have failed in the HFFM group, 5 of patients
were escalated to HFNP, and 7 to NIV, with only 3 of patients in the
HFNP group requiring escalation to NIV.
Interestingly, these comparative studies7,9,2024 describe the use
of HFNP with a ow rate between 30 and 45 L/min. In our study
we report a median ow of 30 L/min with HFNP during the ICU
stay in the after period compared with a median ow of 42 L/min
with HFFM in the before period (Table 2). The terminology associated with these devices may at times be misleading when ow
rates reported are below what is generally accepted as high ow.
There was however an increase in median ow rates on discharge
from 3 L/min to 20 L/min which perhaps represents a reduction in
SNP use with associated increase HFNP device use on discharging
patients to ward areas. In addition, local hospital policy mandates
a minimum of 15 L/min ow when HFNP used in ward areas.
Our study demonstrates a 14-fold improvement in the use of
regulated humidication therapy in association with HFNP. Appropriate humidication of oxygen therapy is important in an attempt
to minimise mucus membrane dehydration, cilia dysfunction and
retention of secretions. 6,7,25,26 Humidication of oxygen therapy
is recommended in multiple clinical guidelines and is emerging
as the standard of care.1012 A rich vascular system, pseudostratied ciliated epithelium and goblet cells are normally responsible
for the maintenance of the isothermic saturation boundary (ISB)
just below the level of the carina. The ISB is the point in the
respiratory tract where inspired gas reaches 37 and a relative
humidity of 100%.27 The maintenance of this normal physiologic
process may be altered with different respiratory or oxygen delivery devices. Current active humidication systems, such as simple
passover water baths, are inefcient when used in conjunction
with traditional oxygen therapy delivery systems, with unregulated temperature control and an inability to maintain 100% relative
humidity in the circuit.2830 The role of properly conditioning cold
gas by means of active regulated humidication is well established
during invasive31,32 and non-invasive33,34 ventilation therapies.
In mechanically ventilated patients, humidication systems aim
to limit any damage to respiratory epithelium reducing patients
work of breathing, reduce atelectasis, improve secretion clearance
and prevent brochospasm.31 In non-invasively ventilated patients
such as those receiving CPAP or BiPAP, humidication is still recommended despite these systems using the normal respiratory tract
warming mechanisms. 33,34 The use of cold medical gas and NIV
are associated with increases in nasal resistance, work of breathing and an increase in risk of intubation difculties after failure
of non-invasive ventilation.5 The impact of humidication techniques in association with spontaneously breathing oxygen devices

has not been adequately investigated.35 Most literature devoted to

the success of HFNP point to patient acceptability in terms of comfort and tolerance as a signicant contributor in the improvement
of overall treatment effectiveness.9,21,22 The role of active humidication systems with high ow oxygen devices, particularly in
the post extubation phase and relationship to adverse patient outcomes such as re-intubation and requirement for NIV has not been
established.
Finally, cost and access to oxygen delivery devices and oxygen supplies are important health care considerations, especially in
developing countries of remote locations. The ndings of our study
identied a cost saving associated with the introduction of a HFNP
protocol in our tertiary metropolitan ICU. The majority of the cost
saving was associated with the reduction in use of HFFM kits. Cost
savings may be attributed to an increased number of mechanically
ventilated patients in the after period as the use of existing ventilator circuits for use with the HFNP setup and therefore a reduced
number of alternative devices and their associated costs. Certainly
a reduction in the number of different devices used per patient stay
in the after period may also have also contributed to any cost savings seen in our study. Understanding the economic implications
of a change in oxygen delivery practice is important given the ever
present nancial pressures on healthcare. Indeed, the cost benet associated with reduced per-patient device use may reect local
conditions with the availability of devices and local oxygen therapy
practices. The requirement for regulated humidier bases in ICU
and to wards receiving discharged patients with HFNP should be a
consideration for estimating any cost benet in instituting a similar
policy. However, while intensive care clinicians have a responsibility to use health care resources appropriately, clinical need should
remain the driver for oxygen therapy related decisions.
4.3. Implications for nursing practice
Our study ndings suggest that an oxygen therapy protocol
stipulating the primary use of HFNP for all ICU care can be safely
implemented for non-intubated intensive care patients and lead
to cost-savings. In addition, they demonstrate a dramatic increase
in the use of humidication during oxygen therapy in our setting. These observations imply that HFNPs provide a safe, feasible,
cost-effective humidied oxygen delivery system in ICU patients
and may be considered as the primary oxygen delivery system in
such patients following extubation. Furthermore, the key patientcentred outcomes of comfort and compliance associated with HFNP
warranted exploration.
4.4. Strengths and weaknesses
Our study has several strengths. They include a prospective
design, standardised data collection methods, veriable outcomes
and capture of 100% of available patients in the ICU. By using a
structured case report forms and chart review to explore the activities of nurses throughout the entirety of patients ICU admission,
information regarding how intensive care nurses adapt to protocolised process in relation to supplemental oxygen therapy. However,
there are limitations that need to be considered when interpreting our ndings. This was not a randomised or blinded controlled
trial, making selection potentially biased and concealment absent.
This study was set in a single institution and as such these ndings may not reect practice of other adult ICUs or paediatric ICUs.
However, given the universal use of oxygen therapy devices and
the inclusion of all intensive care patients in the respective study
periods, applicability of the ndings to other ICUs is possible. In
addition, our study examined the introduction of HFNP as the primary oxygen delivery device during non-invasive ventilation. We

Please cite this article in press as: Fealy N, et al. Nasal high-ow oxygen therapy in ICU: A before-and-after study. Aust Crit Care (2015),
http://dx.doi.org/10.1016/j.aucc.2015.05.003

G Model
AUCC-279; No. of Pages 6

ARTICLE IN PRESS
N. Fealy et al. / Australian Critical Care xxx (2015) xxxxxx

do not evaluate the use of other devices or equipment that are capable of providing humidied oxygen therapy as this was beyond the
scope of our study. Limitations of chart reviews include unrecorded
information or care delivered and not documented on observation
charts.36 However, given the high level of documentation for ICU
patients, we consider that major omissions would have been distributed evenly between both periods. Finally, while some patients
may have had their oxygen delivery device replaced during their
admission, we were not able to determine the number or types of
device replaced and therefore have not incorporated this into our
cost analysis.
5. Conclusions
In conclusion, we found a HFNP oxygen therapy protocol was
feasible, appears safe and resulted in reduced oxygen delivery
device expenditure. Importantly, our HFNP protocol has provided
greater consistency in the delivery of oxygen therapy and humidication to our non-intubated patients. Our single-centre ndings
support the need for further multi-centric evaluations of HFNP
therapy protocols in non-ventilated intensive care patients.
Authors contributions
All authors have made substantial contributions to the conception and design of the study, acquisition of data, analysis and
interpretation of data; to drafting the article, revising it critically for
intellectual content; and to nal approval of the version submitted.
Conict of interest
Graeme Hart and Nigel Fealy have conducted lecture presentations for Fisher & Paykel, Healthcare. The other authors have no
conicts of interest to disclose.
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Please cite this article in press as: Fealy N, et al. Nasal high-ow oxygen therapy in ICU: A before-and-after study. Aust Crit Care (2015),
http://dx.doi.org/10.1016/j.aucc.2015.05.003