High-flow nasal cannulas: Risks and benefits in response to COVID-19 ... 1 of 9 https://www.myamericannurse.com/high-flow-nasal-cannulas-risks-and-... August 27, 2020 Author(s): Janet M. Reed, MSN, RN, CMSRN; Tracy Dodson, MSN, RN; and Richard E. Fer Nurses need to understand the nuances of this therapy. Takeaways 11/13/2020, 1:39 PM High-flow nasal cannulas: Risks and benefits in response to COVID-19 ... 2 of 9 https://www.myamericannurse.com/high-flow-nasal-cannulas-risks-and-... Nurses should know the risks, benefits, and controversy surrounding high-flow na in adults with COVID-19. Nurses should be able to implement, monitor, and evaluate patients receiving hig cannula therapy. Editor’s note: This article is an early release web exclusive article for the October 2020 issue of the American Nurse Jo Novel and unconventional strategies continue to emerge in response to the SARS-Co (COVID-19). One recent innovative response is high-flow nasal cannula (HFNC) use experiencing the respiratory effects of COVID-19. HFNC provides warmed, humidifie higher fractions of inspired oxygen (FiO2) levels and flow rates than conventional oxy potentially reducing the number of patients requiring intubation and mechanical ven Increased HFNC use stems from an attempt to mitigate the virus’s devastating pulm effects, including alveolar inflammation that leads to scarring and respiratory compro persist after the virus has been treated. However, HFNC is controversial because of limited and inconsistent research and the aerosolization of virus particles. This article discusses the delivery of HFNC, its benef and nursing considerations. Recommendations for traditional nasal cannulas were initially limited to low-flow oxy to 6 L/min to reduce patient discomfort and mucosal tissue drying. In the early 2000 studies emerged on the use of HFNCs (up to 40 L/min) that could achieve FiO2 levels to or higher than non-rebreather masks. By using warmed and humidified oxygen, H mucosal drying. In perinatal care, healthcare providers have used HFNC for several d treat premature neonates with respiratory distress syndrome. Now it’s being used w COVID-19–related acute respiratory failure and hypoxemia when noninvasive ventila preferred. Usually, HFNC is offered with heated, humidified air; although nonheated options are can be titrated at different FiO2 levels based on manufacturer recommendations. Oxy delivered through a wide-bore, nasal cannula with flow rates typically at 20 to 35 L/m rates can go as high as 60 L/minute) and FiO2 ranging from 21% to 100%, dependin patient’s clinical response. Patients can be weaned down to a conventional low-flow when appropriate (usually 1 to 6 L/minute or per facility protocol). HFNC is most app used in monitored units—such as ICUs, step down units, or emergency departments oximetry alarms. 11/13/2020, 1:39 PM High-flow nasal cannulas: Risks and benefits in response to COVID-19 ... 3 of 9 https://www.myamericannurse.com/high-flow-nasal-cannulas-risks-and-... With warmed humidification to hydrate airways, HFNC provides many respiratory be addition to improved oxygenation. It decreases cardiac and breathing workload, whi reduces carbon dioxide production, and it reduces dead space in the lungs by increas area available for gas diffusion and providing positive airway pressure (continuous p airway pressure [CPAP] effect). In addition, HFNC helps reduce the body’s energy wo reducing inspiratory effort, improving lung compliance, and by increasing mucus and function, resulting in decreased caloric expenditure. The low-level positive pressure g HFNC increases lung volume and improves gas exchange when oxygen flow is maint highest level tolerated by the patient. Avoiding mechanical ventilation and intubation long-term complications such as infections, tracheostomies, and scarring. Clinical studies show a greater patient acceptance and comfort level for HFNC when with standard masks or non-rebreather masks. This may be attributed to being able drink, and speak more easily. HFNC also can reduce the claustrophobia some patient when wearing facemasks. (See HFNC vs. mechanical ventilation.) HFNC vs. mechanical ventilation High-flow nasal cannula (HFNC) offers some benefits over mechanical ventilation. HFNC Mechanical ventilation · Potential irritation to trachea · Increased patient comfort · Sedation needed · Invasive · Noninvasive · Potential need for emergency intubation and mechanical ventilation if HFNC fails · Potential need for tracheostomy if be removed from ventilator · Other long-term complications suc infection · Patients sedated with communicat deficits · Patients can communicate, eat, and · Need for alternative feeding routes drink · Potential for malnutrition 11/13/2020, 1:39 PM High-flow nasal cannulas: Risks and benefits in response to COVID-19 ... 4 of 9 · Limited mobility possible https://www.myamericannurse.com/high-flow-nasal-cannulas-risks-and-... · Immobility complications (constipa debility, pressure injuries) due to be HFNC is one of several modalities for noninvasive ventilation; the European Society o Care Medicine suggests HFNC as first-line therapy for patients with COVID-19. Howe persists that HFNC high-flow rates may increase airborne transmission of the virus v aerosolization. This concern has led many healthcare facilities to create policies limit mask and CPAP and bilevel positive airway pressure device use in patients with susp confirmed COVID-19. Risk of healthcare worker infection from virus particles spread environment is directly correlated with the flow rate of these devices. To reduce this risk, patients on HFNC are placed in private, negative-pressure, airbo rooms with anterooms. Staff use full personal protective equipment (PPE) for airborn precautions, including water-resistant gowns, N95 masks, face shields or goggles, an Many organizations that use HFNC require patients to wear a surgical mask when sta room to reduce the risk of aerosolization, but this practice hasn’t been well-studied f Surgical masks may reduce carbon dioxide clearance, so nurses and other healthcar should limit the time patients on HFNC wear surgical masks, watch for increased wo breathing during mask wearing, and titrate FiO2 as necessary. Although no absolute contraindications to HFNC exist, its use should be carefully considered in patients wit level of consciousness on the Glasgow Coma Scale, reduced upper airway reflexes, e claustrophobia, risk for aspiration, or unstable hemodynamics. The lack of research documenting improved clinical outcomes, such as reduced mort decreased need for mechanical ventilation, has led some healthcare providers to bel hasn’t met the threshold of doing more good than harm. In fact, current research in HFNC doesn’t improve overall patient mortality, even though patients tolerated HFNC conventional oxygen therapy. Some healthcare providers believe this lack of researc respiratory status of patients on HFNC will continue to decline, resulting in emergenc and mechanical ventilation. Rather than HFNC, some experts advocate early intubati patients with deteriorating respiratory status who require more than 6 L/min of oxyg approach may be reasonable when ventilators aren’t in short supply. More research prevalence of HFNC failure is needed to draw definitive conclusions. To reduce healthcare worker exposure to the virus and promote optimal patient care 11/13/2020, 1:39 PM High-flow nasal cannulas: Risks and benefits in response to COVID-19 ... 5 of 9 https://www.myamericannurse.com/high-flow-nasal-cannulas-risks-and-... actions must be considered. Nurses and hospital administration should work togethe sufficient staff to care for patients on HFNC and reduce exposure, and they should cl emerging evidence on virus transmission and safe care practices. (See HFNC overvie HFNC overview Understanding how high-flow nasal cannula (HFNC) works, the steps for providing treatment, and proper monitoring and management will help ensure good patient Mechanisms of action HFNC: provides noninvasive oxygenation with precise and higher FiO2 levels that can b based on patient needs uses warmed gas to minimize airway constriction; humidification keeps respirat mucosa moist for comfort and respiratory secretion mobilization uses positive airway pressure to keep alveoli open, reduce dead space, and imp exchange washes out anatomical dead space and decreases carbon dioxide to improve ve decreases breathing workload and energy expenditure. Set-up Follow these steps for setting up HFNC: Collect proper equipment, including correct size of nasal prong and tubing lengt may have to choose between small or larger adult sizes depending on the manu Ensure humidification fluid is in place and heating circuit is functioning. A dust f be used over the room air intake port. Adjust the flow rate first, then titrate FiO2 to appropriate levels. Insert the cannula into the patient’s nostrils and secure it to the patient’s head elastic strap to prevent lateral air loss. Monitor the patient’s skin surrounding the nostrils under and around HFNC to id potential skin breakdown or pressure injuries. Adjust the head strap to patient’s head, carefully avoiding the ears; don’t overt Secure the head strap clip to the nasal cannula and clip HFNC tubing to the pat to relieve tension. Maintain the patient in semi-Fowler’s position and consider periodic prone posit promote lung expansion. Ensure suction equipment is present in the room. Monitor the patient for comfort and tolerance. 11/13/2020, 1:39 PM High-flow nasal cannulas: Risks and benefits in response to COVID-19 ... 6 of 9 https://www.myamericannurse.com/high-flow-nasal-cannulas-risks-and-... Nursing care Your nursing care of patients on HFNC should include the following: Educate the patient about the need for frequent coughing and deep breathing e If you’re caring for patients with COVID-19 who are on HFNC, follow these steps to particle spread: Don and doff all PPE in the correct order. Dispose of or clean PPE properly. Adhere to strict surface and equipment decontamination practices. Cluster care to limit patient contact and reduce exposure risk. Place a surgical mask over the patient’s HFNC device to reduce viral aerosolization room. Avoid transporting patients out of their rooms. Ensure that patients are placed in a negative-pressure room to allow for ventilatio regular air exchanges. Properly fitted cannula A properly fitted cannula reduces the risk of facial pressure injuries and healthcare s to aerosolized virus particles. Completely insert the cannula into the patient’s nostril it with elastic straps to the patient’s head to prevent lateral air loss. Ensure the strap head isn’t over the patient’s ears and adjust it to fit the head without overtightening strap clip should be securely attached to the nasal cannula. The nasal prong diameter should be approximately half the size of the patient’s nost the risk of air leak and resulting loss of positive airway pressure and potential virus aerosolization. Having small adult/pediatric and adult size nasal cannulas readily ava help ensure proper fit. Maintain the patient in semi-Fowler’s position and use periodi positioning to aid lung expansion and redistribute pulmonary blood flow to increase Ensure suction equipment is easily accessible, and teach patients coughing and deep exercises to clear the lungs. Patient monitoring and assessment The greatest concern for patients on HFNC is the need for emergent intubation if tre so your early recognition of changes in the patient’s condition is essential. Track tren signs and look for any increased work of breathing (elevated heart rate, elevated res rate, blood pressure changes, and decreased oxygen saturation levels). Titrate oxyg 11/13/2020, 1:39 PM High-flow nasal cannulas: Risks and benefits in response to COVID-19 ... 7 of 9 https://www.myamericannurse.com/high-flow-nasal-cannulas-risks-and-... according to the patient’s respiratory rate and work of breathing for a targeted oxyg no higher than 96% or per facility protocol. Monitor the patient for potential respirat compromise such as declining oxygen saturation (as measured by pulse oximetry), t use of accessory muscles, intercostal recession, abdominal distension, secretions in and changes in lung sounds. Measure arterial blood gases daily and watch for FiO2 ti changes in patient condition. Interpret and report results to the provider immediatel The American Heart Association recommends that providers assess patients at 1 hou hours after HFNC initiation to determine response and whether intubation should be Intubation shouldn’t be delayed if the patient isn’t improving. A growing body of evidence supports the use of HFNC as an effective modality for ea treatment of adults with hypoxemia and respiratory failure, including those with COV line nurses must be knowledgeable about the benefits and risks of this therapy and c the interprofessional team, including respiratory therapists and providers, as needed research emerges and hospital policies evolve, nurses must stay knowledgeable abo based practices and advocate for the best oxygen delivery methods. Janet M. Reed is an associate lecturer in nursing at Kent State University at Stark in N Ohio. Tracy Dodson is a lecturer, clinical faculty, and course coordinator at the Colleg Kent State University in Kent, Ohio. Richard E. Ferdig is summit professor of learning in the Research Center for Educational Technology at Kent State University. References Alhazzani W, Møller MH, Arabi YM, et al. Surviving Sepsis Campaign: Guidelines on t management of critically ill adults with coronavirus disease 2019 (COVID-19). Intens Med. 2020:1-34. American Heart Association. Oxygenation and Ventilation of COVID-19 patients. 202 cpr.heart.org/-/media/cpr-files/resources/covid-19-resources-for-cpr-training/oxygen ventilation-of-covid-19-patients/ovcovid_mod1_nppvhfnc_200401_ed.pdf?la=en& hash=8DA0793B37E4A28DE120BEB7003ACEC46CA28148 Davenport L. Noninvasive ventilatory support in COVID-19: Friend or foe? Medscape medscape.com/viewarticle/928259#vp_2 Galiatsatos P. What coronavirus does to the lungs. John Hopkins Medicine. April 13, 2 11/13/2020, 1:39 PM High-flow nasal cannulas: Risks and benefits in response to COVID-19 ... 8 of 9 https://www.myamericannurse.com/high-flow-nasal-cannulas-risks-and-... hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/what-coronaviruslungs Gattinoni L, Chiumello D, Caironi P. et al. COVID-19 pneumonia: Different respiratory for different phenotypes? Intensive Care Med. 2020;46(6):1099-1102. Helviz Y, Einav S. A systematic review of the high-flow nasal cannula for adult patien 2018;22(1):71. Hernández G, Roca O, Colinas L. High-flow nasal cannula support therapy: New insig improving performance. Crit Care. 2017;21(1):1-11. Loh N, Tan Y, Taculod J, et al. The impact of high-flow nasal cannula (HFNC) on coug distance: Implications on its use during the novel coronavirus disease outbreak. Can 2020;67(7):893-4. Mauri T, Turrini C, Eronia N, et al. Physiologic effects of high-flow nasal cannula in ac hypoxemic respiratory failure. Am J Respir Crit Care Med. 2017;195(9):1207-15. Rali AS, Nunna KR, Howard C, Herlihy JP, Guntupalli KK. High-flow nasal cannula oxy revisited in COVID-19. Card Fail Rev. 2020;6:e08. Tiglis M, Neagu TP, Diaconu C, et al. The importance of high flow nasal cannula (HFN therapy. Modern Medicine. 2019;26(1):1-4. Tinelli V, Cabrini L, Fominskiy E, et al. High flow nasal cannula oxygen vs. convention therapy and noninvasive ventilation in emergency department patients: A systematic meta-analysis. J Emerg Med. 2019;57(3):322-8. Wang K, Zhao W, Li J, Shu W, Duan J. The experience of high-flow nasal cannula in h patients with 2019 novel coronavirus-infected pneumonia in two hospitals of Chongq Ann Intensive Care. 2020;10(1):37. Whittle JS, Pavlov I, Sacchetti AD, Atwood C, Rosenberg MS. Respiratory support for patients with COVID-19 [published online ahead of print April 13, 2020]. J Am Coll E Physicians Open. 2020. ncbi.nlm.nih.gov/pmc/articles/PMC7228246/ 11/13/2020, 1:39 PM High-flow nasal cannulas: Risks and benefits in response to COVID-19 ... 9 of 9 https://www.myamericannurse.com/high-flow-nasal-cannulas-risks-and-... 11/13/2020, 1:39 PM
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