Appropriate Use of High-Flow Nasal Oxygen in Hospitalized Patients

Patricia Kritek, MD


High-flow nasal cannulae generally should be used in hypoxemic patients.
This is the first guideline focused solely on use of high-flow nasal cannulae (HFNC). Recommendations were based on best available evidence as well as patient values and preferences, potential risks and benefits, and cost.
Key Points

  • Patients with hypoxemic respiratory failure should be treated initially with HFNC as opposed to noninvasive ventilation (NIV).
  • Patients with postextubation hypoxemia should be treated with HFNC as opposed to conventional oxygen therapy.



Use of HFNC to support hypoxemic patients has increased dramatically in the past decade, but guidance on when it is the best option and when it should be avoided has been minimal. Although the evidence of benefit is low quality, using HFNC as a first step in managing hypoxemic respiratory failure makes sense: It is less expensive than NIV and generally is well tolerated. Data suggest lower short-term mortality and less progression to intubation with HFNC than with NIV. The recommendation for postextubation support is reasonable but is a conditional recommendation because of the paucity of data.


Qaseem A et al. Appropriate use of high-flow nasal oxygen in hospitalized patients for initial or postextubation management of acute respiratory failure: A clinical guideline from the American College of Physicians. Ann Intern Med 2021 Apr 27; [e-pub]. (


Baldomero AK et al. Effectiveness and harms of high-flow nasal oxygen for acute respiratory failure: An evidence report for a clinical guideline by the American College of Physicians. Ann Intern Med 2021 Apr 27; [e-pub]. (

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