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High-flow therapy: physiological effects and clinical applications

Rebecca F. D'Cruz, Nicholas Hart, Georgios Kaltsakas
Breathe 2020 16: 200224; DOI: 10.1183/20734735.0224-2020
Rebecca F. D'Cruz
1Lane Fox Clinical Respiratory Physiology Research Centre, Guy's and St Thomas’ NHS Foundation Trust, London, UK
2Centre for Human & Applied Physiological Sciences, King's College London, London, UK
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  • ORCID record for Rebecca F. D'Cruz
  • For correspondence: rebecca.d'cruz@kcl.ac.uk4
Nicholas Hart
1Lane Fox Clinical Respiratory Physiology Research Centre, Guy's and St Thomas’ NHS Foundation Trust, London, UK
2Centre for Human & Applied Physiological Sciences, King's College London, London, UK
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Georgios Kaltsakas
1Lane Fox Clinical Respiratory Physiology Research Centre, Guy's and St Thomas’ NHS Foundation Trust, London, UK
2Centre for Human & Applied Physiological Sciences, King's College London, London, UK
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Figures

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  • Figure 1
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    Figure 1

    Schematic of HFT equipment and settings display: temperature (in °C), flow rate 
(in L·min−1) and FIO2.

  • Figure 2
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    Figure 2

    Changes in neural respiratory drive (quantified using EMGpara) in a patient with stable COPD. a) Neural respiratory drive quantified with EMGpara in a patient with very severe COPD (forced expiratory volume in 1 s <30% predicted). Neural respiratory drive index (the product of normalised EMGpara and respiratory rate, AU=arbitrary units) was measured at baseline and with HFT delivered at 10, 20, 30, 40 and 60 L·min−1 at 37°C, FIO2 0.21. Panels b) and c) illustrate raw EMGpara (mV, green), root mean square EMGpara (µV, orange) and respiratory rate (breaths·min−1, blue). b) High neural respiratory drive observed at baseline. c) Optimal offloading of the respiratory muscle pump observed at 30 L·min−1, with a significant reduction in neural respiratory drive.

Tables

  • Figures
  • Table 1

    Physiological effects of humidified high-flow therapy

    Physiological effectImpact
    Mucociliary clearance
    • Optimised respiratory epithelial function

    • Improved mucociliary transport in bench studies

    Dead space washout
    • Reduced anatomical dead space

    • Carbon dioxide washout and oxygen reservoir

    Improved pulmonary mechanics
    • Reduced work of breathing

    • Increased lung compliance

    • Improved gas exchange

    • Improved ventilation homogeneity

  • Table 2

    Evidence-based indications for humidified high-flow therapy

    Clinical indicationEffects
    Acute hypoxaemic respiratory failure [8, 25]
    • Similar rates of intubation compared with NIV and facemask oxygen

    • Reduced risk of intubation in patients with moderate or severe hypoxaemia (PaO2:FIO2 ≤200)

    • Reduced ICU and 90-day mortality

    • Improved breathlessness following treatment initiation

    Prevention of post-extubation respiratory failure [9, 26]
    • Low-risk patients: HFT superior to conventional oxygen

    • High-risk patients: HFT noninferior to NIV

    Breaks from positive airway pressure [27]
    • Permits oral intake (medication, nutrition) and communication

    • More comfortable than conventional nasal cannula and NIV

    Oxygenation during airway procedures [28, 29]
    • Pre-oxygenation prior to and during endotracheal intubation

    • Improves oxygenation during bronchoscopy compared with conventional nasal cannula

    PaO2: arterial oxygen tension; ICU: intensive care unit.

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    Vol 16 Issue 4 Table of Contents
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    High-flow therapy: physiological effects and clinical applications
    Rebecca F. D'Cruz, Nicholas Hart, Georgios Kaltsakas
    Breathe Dec 2020, 16 (4) 200224; DOI: 10.1183/20734735.0224-2020

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    High-flow therapy: physiological effects and clinical applications
    Rebecca F. D'Cruz, Nicholas Hart, Georgios Kaltsakas
    Breathe Dec 2020, 16 (4) 200224; DOI: 10.1183/20734735.0224-2020
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    • Article
      • Abstract
      • Abstract
      • A practical approach to setup and delivery
      • Physiological effects on the respiratory system
      • Evidence-based clinical applications
      • Speculation on emerging applications
      • High-flow therapy during the COVID-19 pandemic
      • Conclusion
      • Footnotes
      • References
    • Figures & Data
    • Info & Metrics
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    • Respiratory clinical practice
    • Acute lung injury and critical care
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