REVIEW

CURRENT
OPINION High-flow nasal cannula oxygen therapy in patients
undergoing thoracic surgery: current evidence
and practice
Jakob Wittenstein a, Lorenzo Ball b,c, Paolo Pelosi b,c,
and Marcelo Gama de Abreu a

Purpose of review
Patients undergoing thoracic surgery are at high risk for pulmonary and extra pulmonary complications,
and may develop impairment of gas exchange during surgery and in the postoperative period. This review
focuses on the potential benefits of high-flow nasal cannula (HFNC) oxygen therapy in those patients.
Recent findings
HFNC oxygen therapy can be used pre, intra and postoperatively. However, evidence for the use of HFNC
oxygen therapy is still limited. Most trials investigated the effects of HFNC oxygen therapy in the
postoperative period only, with promising beneficial effects. Preoperative HFNC oxygen therapy might be
an alternative to conventional techniques, and allows continuous oxygenation during the apneic time of
laryngoscopy. In certain patients, thoracic surgery might be performed in awake and nonintubated patients
who are breathing spontaneously. Under these conditions, HFNC oxygen therapy might be considered for
respiratory support by experienced anesthesiologists. In the postoperative period, HFNC oxygen therapy
can prevent escalation of respiratory management and has the potential to reduce the length of hospital
stay. Throughout the perioperative period, close monitoring of patients receiving HFNC oxygen therapy is
key, and intubation criteria to avoid delayed intubation should be defined a priori to prevent harm.
Summary
HFNC oxygen therapy is a promising tool in the perioperative care of thoracic surgical patients, when
properly set, performed by experienced staff and closely monitored.
Keywords
cardiothoracic surgery, high-flow nasal cannula, oxygen therapy, perioperative management,
postoperative complications

INTRODUCTION (Fig. 1), although not always [3]. Potential benefits

Patients undergoing thoracic surgery are at high risk are improved oxygenation, reduction of dyspnea,
for pulmonary and extra pulmonary complications work of breathing and respiratory rate with an
[1]. The use of high-flow nasal cannula (HFNC) increase of both end-expiratory lung volume (EELV)
oxygen therapy pre, intra and postoperatively offers and tidal volume (Vt), while improving patient
&

a new promising technique to improve lung func- comfort [4 ,5]. HFNC oxygen therapy creates a
tion and possibly also patient outcome.
HFNC oxygen therapy delivers a humidified and a
Department of Anesthesiology and Intensive Care Medicine, Pulmonary
heated mixture of air and oxygen with a FiO2 Engineering Group, University Hospital Carl Gustav Carus, Technische
between 0.21 and 1.0 at a flow of up to 80 l/min Universität Dresden, Dresden, Germany, bDepartment of Surgical Sci-
ences and Integrated Diagnostics, University of Genoa and cSan Martino
[2]. In addition to stand-alone devices, some man-
Policlinico Hospital, IRCCS for Oncology, Genoa, Italy
ufacturers offer a HFNC oxygen therapy option
Correspondence to Marcelo Gama de Abreu, MD, MSc, PhD, DESA,
integrated into the ventilator. Depending on the Department of Anesthesiology and Intensive Care Medicine, Pulmonary
manufacturer, maximum flow, type of humidifica- Engineering Group, University Hospital Carl Gustav Carus, Technische
tion and the design of the nasal cannula differ. Universität Dresden, Fetscher Strasse 74, 01307 Dresden, Germany.
HFNC oxygen therapy is simple to apply and offers Tel: +49 351 458 4488; e-mail: [email protected]
several advantages over conventional oxygen ther- Curr Opin Anesthesiol 2019, 32:44–49
apy and noninvasive mechanical ventilation (NIV) DOI:10.1097/ACO.0000000000000682

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 HFNC oxygen therapy in thoracic surgery Wittenstein et al.

pronounced when the mouth is kept closed while

KEY POINTS HFNC oxygen therapy is applied [6] and in this case
 HFNC oxygen therapy can improve oxygenation and PEEP values of up to 5 cmH2O can be achieved [7].
CO2 washout with enhanced patient comfort as Furthermore, the flush of nasopharyngeal dead
compared to other techniques both in the pre and space with fresh air during expiration can lead to
postoperative periods, including induction of &
washout of carbon dioxide (CO2) [8 ], decreasing
anesthesia. anatomical dead space. This particular advantage
 Use of HFNC oxygen therapy in nontubed awake differs importantly from NIV, which usually
thoracic anesthesia is attractive, but should be used increases the external dead space (Table 1). In addi-
&
only by experienced anesthesiologists. tion, gaseous mixing adds to the CO2 clearance [8 ].
The CO2 clearance seems to be flow-dependent [9]
 The potential of HFNC oxygen therapy to inflict injury
and might contribute to the improvement of dys-
to lungs by excessive mechanical stress is likely lower
than with other techniques, for example noninvasive pnea. HFNC oxygen therapy offers a heated and
positive pressure ventilation. humidified gas mimicking physiological condi-
tions. Therefore, mucociliary function, for example
 Close patient monitoring and predefined intubation fluidity secretion and clearance is not altered [10].
criteria are necessary in order to identify HFNC
HFNC oxygen therapy is usually well tolerated by
oxygen therapy failures and associated patient harm.
patients, and can overcome limitations of NIV such
as eating, drinking and communicating during the
therapy [11]. Extra-pulmonary interactions of HFNC
flow-dependent positive airway pressure, so-called oxygen therapy are comparable with those of NIV,
positive end-expiratory pressure (PEEP) effect, for example under HFNC oxygen therapy a reduc-
which increases end-expiratory transpulmonary tion of cardiac preload was observed [12].
pressure. The increased alveolar pressure results in While NIV can worsen lung injury leading to so
a decreased hydrostatic capillary-alveolar gradient called patient self-inflicted lung injury (P-SILI) [13],
and an increase of airways caliber. This effect is more HFNC oxygen therapy might reduce the risk of

FIGURE 1. Putative beneficial mechanisms of high flow nasal cannula (HFNC) oxygen therapy. EELV, end-expiratory lung
volume; FiO2, inspiratory oxygen fraction; Temp., temperature.

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Thoracic anesthesia

Table 1. Comparison of high-flow nasal cannula oxygen therapy with noninvasive ventilation

Characteristic HFNC NIV

Comfort Higher comfort Lower comfort

Eating, drinking and speaking less impaired Eating, drinking and communicating impaired
or not possible
Airway pressure and PEEP Excessive pressure is likely avoided Excessive pressure could be achieved
Flow-dependent PEEP, limited to 6 cmH2O PEEP can be set directly, values >6 cmH2O possible
Anatomical dead space Mostly reduced Possibly increased
CO2 washout Nasopharyngeal CO2 washout CO2 washout limited
Mucociliary function Maintained due to heated and humidified Maintained due to heated and humidified
gas application gas application
Pulmonary effects Increased EELV Increased EELV
Reduced WOB Reduced WOB
Moderate increase of transpulmonary pressure Risk of higher transpulmonary pressure
Extra pulmonary effects Reduction of cardiac preload Reduction of cardiac preload
P-SILI/VILI Lower risk Increased risk
Skin breakdown/sores Less likely More likely

PEEP, positive end-expiratory pressure; EELV, end-expiratory lung volume; WOB, work of breathing; P-SILI/VILI, patient self-inflicted lung injury/ventilator induced
lung injury; HFNC, high-flow nasal cannula; NIV, noninvasive ventilation.

further lung injury. Mauri and collogues saw a INTRAOPERATIVE USE OF HIGH FLOW:
decrease in driving transpulmonary pressure swings NON-TUBED PROCEDURES
along inspiration and an increase of end-expiratory One-lung ventilation impairs oxygenation and, to a
lung volume induced by HFNC oxygen therapy with lesser extent, CO2 removal, Also it can lead to mac-
unchanged VT resulting in a lower lung strain [14]. roscopic, microscopic and biochemical injury of the
With HFNC oxygen therapy compared with NIV lungs such as airway injury, impaired mucociliary
high VT and high transpulmonary pressures might clearance and ventilator induced lung injury, even
be avoided, reducing ventilator induced lung injury when managed with so-called lung protective ven-
and P-SILI [15]. tilation strategies [18,19]. A promising alternative to
a general anesthesia with invasive ventilation is the
so-called awake, nonintubated (nontubed) anes-
PREOPERATIVE USE OF HIGH FLOW thetic management. Novel surgical techniques in
Large randomized trials on the use of HFNC oxygen lung surgery to avoid shortcomings such as long
therapy for preoxygenation are missing. In contrast hospitalization of nonawake interventions are cur-
to other forms of preoxygenation, HFNC oxygen rently under investigation [20]. Nontubed awake
therapy does not need to be removed during laryn- video-assisted thoracic surgery (VATS) might be safe
goscopy and intubation and therefore apnea time for procedures including management of pneumo-
can theoretically be enlarged [16]. Raineri et al. [17] thorax, wedge resection of pulmonary tumors, exci-
showed in a small efficacy and safety study, that sion of mediastinal tumors, lung volume reduction
HFNC oxygen therapy is an effective and safe tech- surgery, segmentectomy and even lobectomy [21–
nique for preoxygenation in patients undergoing 23]. Epidural anesthesia is used in some cases and
rapid sequence induction of general anesthesia for combined with intrathoracic vagal blockade,
emergency surgery. Trials on the use of HFNC because pulling of the pulmonary hilum during
oxygen therapy for preoxygenation in thoracic surgery may stimulate the vagus nerve resulting in
anesthesia are still lacking. coughing [23]. Patients who might benefit most
If HFNC oxygen therapy is used during induc- from avoiding general anesthesia are elderly with
tion of anesthesia in a patient who has no contrain- high risk during general anesthesia, patients with
dication for positive pressure ventilation, bag- neuromuscular disease, for example mystaenia
ventilation can be applied before administering gravis or chronic lung disease, for example chronic
the neuromuscular blocking agent to test airway obstructive lung disease, who a difficult to wean
patency. If complete reversal of the neuromuscular from the ventilator and patients with an anterior
blocking agent in due time is possible then this mediastinal mass. The avoidance of general anes-
affords another level of safety. Importantly, difficult thesia might protect from recurrence or metastases
airway protocols must be always followed. after cancer surgery [21] and postoperative

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 HFNC oxygen therapy in thoracic surgery Wittenstein et al.

impairment of immune function due to general compared with standard oxygen was associated with
anesthesia [24]. In addition, nontubed awake VATS reduced length of hospital stay and improved satis-
with epidural anesthesia might offer better postop- faction after lung resection [31]. The multicenter,
erative pain control, lower rates of sore throat, ear- randomized, noninferiority trial from Stephan et al.
lier resuming of oral intake and shorter length of with a total of 830 patients comparing HFNC oxy-
hospital stay with better noncomplication rates [21]. gen therapy with NIV to prevent and resolve acute
The risk of hypoxemia and hypercapnia during respiratory failure after cardiothoracic surgery also
nontubed VATS remains a concern and the conver- supports the use of HFNC oxygen therapy in similar
sion rate to general anesthesia and endotracheal patients [29]. The same applies to the subgroup of
obese patients (BMI  30 kg/m2) [32]. In a trial by
&
intubation lies between 3 and 10% [25 ]. HFNC
oxygen therapy offers a chance to reduce the risk Parke et al. [33] participants received either HFNC
&
of hypoxemia [25 ]. Under spontaneous breathing oxygen therapy (45 l/min) or usual care within 48 h
during VATS, a paradox respiratory pattern may after cardiac surgery. HFNC oxygen therapy reduced
cause carbon dioxide rebreathing from the nonde- the requirement for escalation of respiratory support.
pendent, collapsed lung [21] which might be To date, it is not clear for how long HFNC oxygen
avoided when HFNC oxygen therapy is applied with therapy should by applied, but patients must be
an adequate flow. However, airflow has to be set carefully monitored, whenever HFNC oxygen ther-
carefully in order not to recruit the nondependent apy is used in order to promptly recognize nonres-
lung during VATS. Also, it should be kept in mind ponders. Clearly, large, properly powered studies
that HFNC oxygen therapy could be combined with with clinical important outcomes are missing [27].
NIV, possibly merging the advantages of both tech-
&
niques [26 ]. It must be emphasized, that clinical
evidence is still emerging on nontubed awake HOW TO SET HIGH-FLOW NASAL
thoracic anesthesia, and especially when used in CANNULA OXYGEN THERAPY
combination with HFNC oxygen therapy, should There is only limited evidence on how to set HFNC
be conducted by experienced anesthesiologists oxygen therapy best. HFNC oxygen therapy almost
competent in these techniques. linearly improved inspiratory drive and effort, oxy-
genation, efficiency of minute ventilation, end-
expiratory lung volume and lung mechanics in
POSTOPERATIVE USE OF HIGH FLOW patients with acute hypoxic respiratory failure at
Postextubation respiratory failure, mainly hypoxia, increasing flow rates [34]. Higher flow seems to
is relatively common after thoracic surgery [27,28]. increase rather than decrease patient comfort, in
&
NIV is frequently used to treat hypoxemia, but more severely hypoxemic patients [35 ]. A simple
adverse events such as low comfort and a high and practical clinical approach could be to start with
number of skin breakdowns are only part of the the highest flow tolerated by the patient and slowly
possible complications [29]. HFNC oxygen therapy decrease it depending on patient comfort and SpO2.
can offer a good alternative to NIV in those patients. In short, the flow must be set to meet the patients
&
Brainard and collegues compared HFNC oxygen inspiratory demand [4 ]. When used for induction
therapy (40 l/min) with standard oxygen therapy of anesthesia, the airflow can be increased rapidly
(face mask or nasal cannula to keep SpO2 > 90%). up to 70 l/min soon after administration of the
The occurrence of a composite of postoperative hypnotic agent.
pulmonary complications was not different During HFNC oxygen therapy set FiO2 almost
between HFNC oxygen therapy (40 l/min) and stan- equals the alveolar FiO2 [36]. Therefore, FiO2 should
dard oxygen therapy (face mask or nasal cannula to be titrated according to SpO2. During induction of
keep SpO2 > 90%), but the trial was likely underpow- anesthesia, the FiO2 should be set at 1.0.
ered, enrolling only 51 patients in total [1]. There is no clear evidence which temperature
In a multicenter randomized interventional trial should be chosen. In patients with acute respiratory
HFNC oxygen therapy reduced the respiratory rate, failure a lower temperature of 318C was associated
improved the oxygenation and reduced the risk of with higher comfort compared with a higher tem-
&
reintubation compared with conventional oxygen perature of 418C [35 ].
therapy after thoracoscopic surgery [30]. In a meta- So far the optimal length of HFNC oxygen ther-
analysis Zhu et al. [11] compared HFNC oxygen apy is unknown. In most trials therapy time was set a
therapy with conventional oxygen therapy after priori, without any widely accepted criteria to guide
cardiothoracic surgery. HFNC oxygen therapy could this therapy. A practical approach would be to
reduce the need for the escalation of respiratory slowly decrease flow and FiO2 and to finally end
support. Prophylactic HFNC oxygen therapy the respiratory support.

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Thoracic anesthesia

MONITORING HIGH-FLOW NASAL REFERENCES AND RECOMMENDED

CANNULA OXYGEN THERAPY READING
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&& of outstanding interest

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