Perioperative use of high flow nasal cannula

High flow nasal cannula during perioperative care


  • Suharit Visuthisakchai Division of Critical Care, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand, 10700
  • Suneerat Kongsayreepong Department of Anesthesiology, Siriraj Hospital, Mahidol University, Bangkok, Thailand, 10700



High flow nasal cannula, Perioperative period, Preoxygenation, Apneic oxygenation, Post-extubation


High flow nasal cannula (HFNC) is an innovative oxygen therapy system that has gained increasing popularity in recent decades, particularly in the field of critical care medicine. The device provides a more constant and higher FiO2, generates low levels of PEEP, reduces dead space ventilation, and conditions the inspired gas, which collectively results in a reduction in work of breathing (WOB) and improved patient comfort. While the application of HFNC in critically ill patients is well-established and supported by a large body of evidence, studies of HFNC during the perioperative period are limited. However, the working mechanisms of HFNC align with physiological demands across various anesthetic processes. Consequently, this system could potentially serve as an alternative oxygen delivery system for surgical patients during perioperative care. In this article, we summarize the working principles and the effects provided by HFNC, review its implementation during the perioperative period, and discuss the current evidence regarding its use.


Rittayamai N. Clinical use of high-flow oxygen therapy. Bangkok: Printable; 2021.

Ischaki E, Pantazopoulos I, Zakynthinos S. Nasal high flow therapy: a novel treatment rather than a more expensive oxygen device. Eur Respir Rev. 2017;26(145).

Nolasco S, Manti S, Leonardi S, Vancheri C, Spicuzza L. High-flow nasal cannula oxygen therapy: physiological mechanisms and clinical applications in children. Frontiers in Medicine. 2022;9.

Spicuzza L, Schisano M. High-flow nasal cannula oxygen therapy as an emerging option for respiratory failure: The present and the future. Ther Adv Chronic Dis. 2020;11:2040622320920106.

Oczkowski S, Ergan B, Bos L, Chatwin M, Ferrer M, Gregoretti C, et al. ERS clinical practice guidelines: High-flow nasal cannula in acute respiratory failure. European Respiratory Journal. 2022;59(4):2101574.

Boscolo A, Pettenuzzo T, Sella N, Zatta M, Salvagno M, Tassone M, et al. Noninvasive respiratory support after extubation: A systematic review and network meta-analysis. Eur Respir Rev. 2023;32(168).

Rochwerg B, Einav S, Chaudhuri D, Mancebo J, Mauri T, Helviz Y, et al. The role for high flow nasal cannula as a respiratory support strategy in adults: A clinical practice guideline. Intensive Care Med. 2020;46(12):2226-37.

Nishimura M. High-flow nasal cannula oxygen therapy in adults: Physiological benefits, indication, clinical benefits, and adverse effects. Respir Care. 2016;61(4):529-41.

Helviz Y, Einav S. A systematic review of the high-flow nasal cannula for adult patients. Crit Care. 2018;22(1):71.

Parke R, McGuinness S, Eccleston M. Nasal high-flow therapy delivers low level positive airway pressure. Br J Anaesth. 2009;103(6):886-90.

Parke RL, McGuinness SP. Pressures delivered by nasal high flow oxygen during all phases of the respiratory cycle. Respir Care. 2013;58(10):1621-4.

Nishimura M. High-flow nasal cannula oxygen therapy in adults. J Intensive Care. 2015;3(1):15.

Parke RL, Eccleston ML, McGuinness SP. The effects of flow on airway pressure during nasal high-flow oxygen therapy. Respir Care. 2011;56(8):1151-5.

Riera J, Pérez P, Cortés J, Roca O, Masclans JR, Rello J. Effect of high-flow nasal cannula and body position on end-expiratory lung volume: A cohort study using electrical impedance tomography. Respir Care. 2013;58(4):589-96.

Corley A, Caruana LR, Barnett AG, Tronstad O, Fraser JF. Oxygen delivery through high-flow nasal cannulae increase end-expiratory lung volume and reduce respiratory rate in post-cardiac surgical patients. Br J Anaesth. 2011;107(6):998-1004.

Mauri T, Turrini C, Eronia N, Grasselli G, Volta CA, Bellani G, et al. Physiologic effects of high-flow nasal cannula in acute hypoxemic respiratory failure. Am J Respir Crit Care Med. 2017;195(9):1207-15.

Möller W, Celik G, Feng S, Bartenstein P, Meyer G, Oliver E, et al. Nasal high flow clears anatomical dead space in upper airway models. J Appl Physiol (1985). 2015;118(12):1525-32.

Möller W, Feng S, Domanski U, Franke KJ, Celik G, Bartenstein P, et al. Nasal high flow reduces dead space. J Appl Physiol (1985). 2017;122(1):191-7.

Fontanari P, Burnet H, Zattara-Hartmann MC, Jammes Y. Changes in airway resistance induced by nasal inhalation of cold dry, dry, or moist air in normal individuals. J Appl Physiol (1985). 1996;81(4):1739-43.

Williams R, Rankin N, Smith T, Galler D, Seakins P. Relationship between the humidity and temperature of inspired gas and the function of the airway mucosa. Crit Care Med. 1996;24(11):1920-9.

Salah B, Dinh Xuan AT, Fouilladieu JL, Lockhart A, Regnard J. Nasal mucociliary transport in healthy subjects is slower when breathing dry air. Eur Respir J. 1988;1(9):852-5.

Hasani A, Chapman TH, McCool D, Smith RE, Dilworth JP, Agnew JE. Domiciliary humidification improves lung mucociliary clearance in patients with bronchiectasis. Chron Respir Dis. 2008;5(2):81-6.

Ricard JD, Roca O, Lemiale V, Corley A, Braunlich J, Jones P, et al. Use of nasal high flow oxygen during acute respiratory failure. Intensive Care Med. 2020;46(12):2238-47.

Pantazopoulos I, Adamos G, Sotiriou A, Chalkias A, Gourgoulianis K, Zakynthinos S, et al. Nasal high flow application for perioperative support of respiratory system in adult patients. Journal of Emergency and Critical Care Medicine. 2019;4.

Kim HJ, Asai T. High-flow nasal oxygenation for anesthetic management. Korean J Anesthesiol. 2019;72(6):527-47.

Donohue C, Hobson B, Stephens RC. An introduction to anaesthesia. Br J Hosp Med (Lond). 2013;74(5):C71-5.

Croft R, Washington S. Induction of anaesthesia. Anaesthesia & Intensive Care Medicine. 2012;13(9):401-6.

Cortegiani A, Accurso G, Mercadante S, Giarratano A, Gregoretti C. High flow nasal therapy in perioperative medicine: From operating room to general ward. BMC Anesthesiology. 2018;18(1):166.

Ang KS, Green A, Ramaswamy KK, Frerk C. Preoxygenation using the Optiflow™ system. BJA: British Journal of Anaesthesia. 2017;118(3):463-4.

Pillai A, Daga V, Lewis J, Mahmoud M, Mushambi M, Bogod D. High-flow humidified nasal oxygenation vs. standard face mask oxygenation. Anaesthesia. 2016;71(11):1280-3.

Mir F, Patel A, Iqbal R, Cecconi M, Nouraei SA. A randomised controlled trial comparing transnasal humidified rapid insufflation ventilatory exchange (THRIVE) pre-oxygenation with facemask pre-oxygenation in patients undergoing rapid sequence induction of anaesthesia. Anaesthesia. 2017;72(4):439-43.

Lodenius Å, Piehl J, Östlund A, Ullman J, Jonsson Fagerlund M. Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) vs. facemask breathing pre-oxygenation for rapid sequence induction in adults: a prospective randomised non-blinded clinical trial. Anaesthesia. 2018;73(5):564-71.

Li Y, Yang J. Comparison of transnasal humidified rapid-insufflation ventilatory exchange and facemasks in preoxygenation: A systematic review and meta-analysis. Biomed Res Int. 2022;2022:9858820.

Tan PCF, Millay OJ, Leeton L, Dennis AT. High-flow humidified nasal preoxygenation in pregnant women: A prospective observational study. Br J Anaesth. 2019;122(1):86-91.

Shippam W, Preston R, Douglas J, Taylor J, Albert A, Chau A. High-flow nasal oxygen vs. standard flow-rate facemask pre-oxygenation in pregnant patients: a randomised physiological study. Anaesthesia. 2019;74(4):450-6.

Heinrich S, Horbach T, B S, Prottengeier J, A I, Schmidt J. Benefits of heated and humidified high flow nasal oxygen for preoxygenation in morbidly obese patients undergoing bariatric surgery: A randomized controlled study. Journal of Obesity and Bariatrics. 2014;1:7.

Vourc'h M, Baud G, Feuillet F, Blanchard C, Mirallie E, Guitton C, et al. High-flow nasal cannulae versus non-invasive ventilation for preoxygenation of obese patients: The PREOPTIPOP randomized trial. EClinicalMedicine. 2019;13:112-9.

Vourc'h M, Asfar P, Volteau C, Bachoumas K, Clavieras N, Egreteau PY, et al. High-flow nasal cannula oxygen during endotracheal intubation in hypoxemic patients: A randomized controlled clinical trial. Intensive Care Med. 2015;41(9):1538-48.

Frat JP, Ricard JD, Quenot JP, Pichon N, Demoule A, Forel JM, et al. Non-invasive ventilation versus high-flow nasal cannula oxygen therapy with apnoeic oxygenation for preoxygenation before intubation of patients with acute hypoxaemic respiratory failure: A randomised, multicentre, open-label trial. Lancet Respir Med. 2019;7(4):303-12.

Fong KM, Au SY, Ng GWY. Preoxygenation before intubation in adult patients with acute hypoxemic respiratory failure: A network meta-analysis of randomized trials. Critical Care. 2019;23(1):319.

Jaber S, Monnin M, Girard M, Conseil M, Cisse M, Carr J, et al. Apnoeic oxygenation via high-flow nasal cannula oxygen combined with non-invasive ventilation preoxygenation for intubation in hypoxaemic patients in the intensive care unit: The single-centre, blinded, randomised controlled OPTINIV trial. Intensive Care Med. 2016;42(12):1877-87.

Ng I, Krieser R, Mezzavia P, Lee K, Tseng C, Douglas N, et al. The use of Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) for pre-oxygenation in neurosurgical patients: A randomised controlled trial. Anaesth Intensive Care. 2018;46(4):360-7.

Ahmed A, Azim A. Difficult tracheal intubation in critically ill. Journal of Intensive Care. 2018;6(1):49.

Patel A, Nouraei SA. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE): A physiological method of increasing apnoea time in patients with difficult airways. Anaesthesia. 2015;70(3):323-9.

Gustafsson IM, Lodenius Å, Tunelli J, Ullman J, Jonsson Fagerlund M. Apnoeic oxygenation in adults under general anaesthesia using Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) - a physiological study. Br J Anaesth. 2017;118(4):610-7.

Lyons C, Callaghan M. Apnoeic oxygenation with high-flow nasal oxygen for laryngeal surgery: A case series. Anaesthesia. 2017;72(11):1379-87.

Jhou HJ, Chen PH, Lin C, Yang LY, Lee CH, Peng CK. High-flow nasal cannula therapy as apneic oxygenation during endotracheal intubation in critically ill patients in the intensive care unit: A systematic review and meta-analysis. Sci Rep. 2020;10(1):3541.

Li LT, Chitilian HV, Alfille PH, Bao X. Airway management and anesthesia for airway surgery: A narrative review. Transl Lung Cancer Res. 2021;10(12):4631-42.

English J, Norris A, Bedforth N. Anaesthesia for airway surgery. Continuing Education in Anaesthesia Critical Care & Pain. 2006;6(1):28-31.

Chan KC, Yang TX, Khu KF, So CV. High-flow nasal cannula versus conventional ventilation in laryngeal surgery: A systematic review and meta-analysis. Cureus. 2023;15(5):e38611.

Tao Y, Sun M, Miao M, Han Y, Yang Y, Cong X, et al. High flow nasal cannula for patients undergoing bronchoscopy and gastrointestinal endoscopy: A systematic review and meta-analysis. Frontiers in Surgery. 2022;9.

Maggiore SM, Idone FA, Vaschetto R, Festa R, Cataldo A, Antonicelli F, et al. Nasal high-flow versus Venturi mask oxygen therapy after extubation. Effects on oxygenation, comfort, and clinical outcome. Am J Respir Crit Care Med. 2014;190(3):282-8.

Hernández G, Vaquero C, González P, Subira C, Frutos-Vivar F, Rialp G, et al. Effect of postextubation high-flow nasal cannula vs conventional oxygen therapy on reintubation in low-risk patients: A randomized clinical trial. Jama. 2016;315(13):1354-61.

Hernández G, Vaquero C, Colinas L, Cuena R, González P, Canabal A, et al. Effect of postextubation high-flow nasal cannula vs noninvasive ventilation on reintubation and postextubation respiratory failure in high-risk patients: A randomized clinical trial. Jama. 2016;316(15):1565-74.

Thille AW, Muller G, Gacouin A, Coudroy R, Decavèle M, Sonneville R, et al. Effect of postextubation high-flow nasal oxygen with noninvasive ventilation vs high-flow nasal oxygen alone on reintubation among patients at high risk of extubation failure: A randomized clinical trial. Jama. 2019;322(15):1465-75.

Branson RD. The scientific basis for postoperative respiratory care. Respir Care. 2013;58(11):1974-84.

Lusquinhos J, Tavares M, Abelha F. Postoperative pulmonary complications and perioperative strategies: A systematic review. Cureus. 2023;15(5):e38786.

Odor PM, Bampoe S, Gilhooly D, Creagh-Brown B, Moonesinghe SR. Perioperative interventions for prevention of postoperative pulmonary complications: systematic review and meta-analysis. BMJ. 2020;368:m540.

Futier E, Paugam-Burtz C, Godet T, Khoy-Ear L, Rozencwajg S, Delay JM, et al. Effect of early postextubation high-flow nasal cannula vs conventional oxygen therapy on hypoxaemia in patients after major abdominal surgery: A French multicentre randomised controlled trial (OPERA). Intensive Care Med. 2016;42(12):1888-98.

Stéphan F, Barrucand B, Petit P, Rézaiguia-Delclaux S, Médard A, Delannoy B, et al. High-flow nasal oxygen vs noninvasive positive airway pressure in hypoxemic patients after cardiothoracic surgery: A randomized clinical trial. Jama. 2015;313(23):2331-9.

Chaudhuri D, Granton D, Wang DX, Burns KEA, Helviz Y, Einav S, et al. High-flow nasal cannula in the immediate postoperative period: A systematic review and meta-analysis. Chest. 2020;158(5):1934-46.




How to Cite

Visuthisakchai S, Kongsayreepong S. Perioperative use of high flow nasal cannula: High flow nasal cannula during perioperative care. Clin Crit Care [Internet]. 2024 May 23 [cited 2024 Jun. 20];32(1):e240010. Available from:



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