Non-ICU Nasal High-Flow Therapy in COPD With Acute Hypoxic Respiratory Failure

Investigators evaluated a hospital protocol change allowing administration of nasal high flow therapy outside the ICU in COPD with acute hypoxic respiratory failure.

For patients with chronic obstructive pulmonary disease (COPD) with acute hypoxic respiratory failure (AHRF), providing nasal high flow (NHF) therapy on medical/surgical wards may spare intensive care unit (ICU) resources without delaying needed care. This was among the findings of a study published in the Clinical Respiratory Journal.

Nasal high flow therapy has proven beneficial in the management of acute hypoxic respiratory failure in diverse settings. Previously, this therapy was relegated to the ICU because its safety and efficacy in non-ICU settings had yet to be supported by data.

In a retrospective study of 90 patients with COPD presenting with acute hypoxic respiratory failure, investigators at an Iowa health system assessed the safety and efficacy of NHF therapy in non-ICU settings including medical/surgical wards. Nasal high flow therapy was started either in the emergency department (49%) or on the ward (51%), per the initiation of a new protocol. Study participants were matched with a historical cohort of 90 patients who received the prior standard of care, which included patients who received low or moderate-flow nasal cannula (up to 15 liters per minute) on the medical/surgical wards or patients who received NHF therapy in the ICU. The primary study endpoint was the difference in the rates of mechanical ventilation.

Patients in the study group did not differ statistically vs. the control group with regard to escalation to mechanical ventilation (8% vs 9%, respectively; P =.79), hospital length of stay (7 days vs 6 days, respectively; P =.02), or in-hospital deaths (12% in both groups; P =.99). ICU-level care was required by 19% of patients in the study group vs 49% of patients in the control group (P <.001).

Notably, the experimental group exhibited decreased initial oxygen saturation versus the control group according to emergency department measures (91% versus 93%, P <.001), as well as lower levels of PCO2 per ABG analysis. Members of the control group demonstrated a mean pH of 7.345 versus 7.403 in the study group (P <.001), with median pH values 7.36 versus 7.41, respectively.

Investigators ultimately concluded that ”Nasal high flow therapy use in patients with acute hypoxic respiratory failure and underlying chronic obstructive pulmonary disease outside of the intensive care unit may spare ICU resources and cost without delay in definitive care such as mechanical ventilation.”

However, investigators also cautioned that because their study was not a randomized controlled trial, and due to other limitations as well, further research is needed before these study results can be generalized.


Trump MW, Ganapathiraju I, Jackson JA, et al. Nasal High Flow Therapy Use in Wards in Patients with Chronic Obstructive Pulmonary Disease May Spare ICU Resources. Clin Respir J. Published online on October 31, 2021. doi: 10.1111/crj.13458