High Flow Nasal Cannula Use: A Survey on Weaning Practices

Abstract

Rationale: High flow nasal cannula (HFNC) is first line therapy for patients with acute hypoxic respiratory failure (AHRF). HFNC utilization among hospitalized patients with AHRF has increased substantially during the COVID-19 pandemic. While good evidence exists to guide initiation of HFNC, evidence-based strategies for HFNC weaning are lacking. Therefore, we sought to characterize HFNC weaning practices among respiratory therapists (RTs) to determine the degree of practice variability and assess general approaches to HFNC weaning. Methods: We conducted a cross-sectional survey evaluating HFNC weaning practices of adult inpatient RTs at an academic, tertiary care medical center in the United States. Survey participants were asked about their practice of HFNC weaning and whether use of an institutional protocol provided guidance for HFNC weaning. Survey questions also assessed RT knowledge of institutional policies regarding HFNC use in hospitalized patients, including location of HFNC use within the hospital, personnel involved in HFNC titration, and methods of weaning through clinical vignettes. Survey responses were analyzed using descriptive statistics. Results: Overall, 21 of 68 RTs surveyed completed the survey (response rate 31%). The majority of participants (95%) worked primarily in an ICU, general wards, or emergency department. Approximately one-third of participants were unaware of a HFNC weaning protocol at their institution. Among those who endorsed the existence of a HFNC weaning protocol at their institution, 79% reported using the protocol “always or often.” We found substantial variation in RT knowledge of institutional policies regarding which practitioners were permitted to wean HFNC, with approximately one-half of participants believing that any practitioner could wean FiO2 and 43% believing that only RTs could wean flow. Additionally, participants' approaches to weaning varied substantially in response to clinical vignettes. For example, in the vignette of a clinically stable patient on HFNC at 60L and 100%, 62% of participants chose to wean only FiO2, 14% to wean only flow, and 24% to wean both. Conclusion: Nearly one-third of respiratory therapists were unaware of the existing HFNC weaning protocol at their institution, potentially contributing to the substantial variability in HFNC weaning practices between surveyed RTs. More research is needed to identify and successfully implement optimal weaning strategies for HFNC among patients hospitalized with AHRF.