High-flow therapy: Where are we today?

Key facts


HFT symposium at ERS 2021

Experts from Spain, Germany and Italy share their experience of using HFT at home for COPD and provide a summary of the evidence.


The use of high-flow therapy (HFT) is increasing, particularly during the COVID-19 pandemic.1 In this seminar, our guest speakers outline the evidence for the use of HFT in different indications, describe some of the key learnings on its use gained during the COVID-19 pandemic and summarise the remaining research questions yet to be addressed.

Dr Dora Triché outlines the clinical benefits of home HFT in patients with COPD and reviews the evidence from pivotal trials in different patient phenotypes. In particular, she describes evidence for HFT in patients with chronic hypoxemic respiratory failure, particularly those with two or more prior exacerbations2,3 and in patients with chronic hypercapnic respiratory failure.4 In addition, the use of HFT during the pandemic is discussed, such as the important issue of aerosol formation. Finally Dr Triché outlines that HFT, long-term oxygen therapy and non-invasive ventilation therapy should be considered complementary therapeutic approaches for COPD. Compared with standard oxygen, HFT appears to be better tolerated 5 and proactive patient management with telemedicine can further improve tolerance.6

Prof. Javier Sayas Catalán and Dr Claudia Crimi describe their experience of HFT during the COVID-19 pandemic in their respective countries. Prof. Sayas Catalán describes his positive experience of using HFT in patients requiring ‘tracheostomy weaning’ in the post-COVID setting, as well as reviewing the clinical evidence for its general use in patients post-tracheostomy.7-10 Other settings discussed are in the training and rehabilitation of COPD patients and — a promising indication requiring more data — in patients with cystic fibrosis.11-13 

Dr Crimi highlights the need to phenotype COPD patients in order to personalise pharmacological and non-pharmacological treatments. HFT provides benefits in secretion management,14,15 work of breathing,16,17 nocturnal alveolar ventilation,18 QoL,2,19 and reduces acute exacerbations and hospitalisation rates.2 In particular, HFT is beneficial for patients with COPD and bronchiectasis20 and patients with COPD (with emphysema) and pulmonary fibrosis. HFT represents an attractive therapeutic option since it improves outcomes of utmost importance to patients (such as QoL, comfort and exercise capacity) as well as those outcomes of prime importance to clinicians (such as work of breathing and respiratory rate).

In summary, the speakers describe how clinical experience with home HFT is expanding. Further research is warranted into the optimal patient type, daily duration of therapy and timings of clinical evaluation and long term follow-up.


  1. Guy T et al. High-flow nasal oxygen: a safe, efficient treatment for COVID-19 patients not in an ICU. Eur Respir J 2020; DOI: 10.1183/13993003.01154-2020.
  2. Storgaard LH et al. Long-term effects of oxygen-enriched high-flow nasal cannula treatment in COPD patients with chronic hypoxemic respiratory failure. Int J Chron Obstruct Pulmon Dis. 2018;13:1195–1205.
  3. Weinreich U. Domiciliary high-flow treatment in patients with COPD and chronic hypoxic failure: In whom can we reduce exacerbations and hospitalizations? PLoS One. 2019;14(12): e0227221.
  4. Bräunlich J et al. Nasal high-flow versus noninvasive ventilation in patients with chronic hypercapnic COPD. Int J Chron Obstruct Pulmon Dis. 2019;14:1411–1421.
  5. Agarwal A et al. High-flow nasal cannula for acute hypoxemic respiratory failure in patients with COVID-19: systematic reviews of effectiveness and its risks of aerosolization, dispersion, and infection transmission. Can J Anesth.2020;67:1217–1248.
  6. Woehrle H et al. Telemedicine-based proactive patient management during positive airway pressure therapy: Impact on therapy termination rate. Somnologie (Berl). 2017;21(2):121–127.
  7. Corley A et al. High-flow oxygen via tracheostomy improves oxygenation in patients weaning from mechanical ventilation: a randomised crossover study. Intensive Care Med. 2017;43(3):465–467.
  8. Natalini D et al. Physiological effects of high-flow oxygen in tracheostomized patients. Annals of Intensive Care. 2019;9(114).
  9. Stripoli T et al. High-flow oxygen therapy in tracheostomized patients at high risk of weaning failure. Annals of Intensive Care. 2019;9:4.
  10. Hernández Martínez G et al. High-Flow Oxygen with Capping or Suctioning for Tracheostomy Decannulation. N Engl J Med. 2020;383:1009–1017.
  11. Loukou I et al. The Current Practice of Noninvasive Ventilation in Patients With Cystic Fibrosis. Respir Care. 2021;66(8):1330–1336.
  12. Sklar M. High-flow nasal oxygen versus noninvasive ventilation in adult patients with cystic fibrosis: a randomized crossover physiological study. Ann Intensive Care. 2018;8(1):85.
  13. Spoletini G et al. Nasal high-flow therapy as an adjunct to exercise in patients with cystic fibrosis: A pilot feasibility trial. J Cyst Fibros. 2021;20(5):e46-e52.
  14. Hasani A et al. Domiciliary humidification improves lung mucociliary clearance in patients with bronchiectasis. Chron Respir Dis. 2008;5(2):81–86.
  15. Rea H et al. The clinical utility of long-term humidification therapy in chronic airway disease. Respir Med. 2010;104(4):525–533.
  16. Fraser JF et al. Nasal high flow oxygen therapy in patients with COPD reduces respiratory rate and tissue carbon dioxide while increasing tidal and end-expiratory lung volumes: a randomised crossover trial. Thorax. 2016;71:759–761.
  17. Pisani L and Vega ML. Use of Nasal High Flow in Stable COPD: Rationale and Physiology. COPD. 2017;14(3):346–350.
  18. Biselli PJC. Nasal high-flow therapy reduces work of breathing compared with oxygen during sleep in COPD and smoking controls: a prospective observational study. J Appl Physiol (1985).2017;122(1):82–88.
  19. Nagata K et al. Domiciliary high-flow nasal cannula oxygen therapy for stable hypercapnic chronic obstructive pulmonary disease: a prospective, multicentre, randomised crossover trial. Eur Respir J. 2017;50: OA4428.
  20. Crimi C et al. High Flow Nasal Therapy Use in Patients with Acute Exacerbation of COPD and Bronchiectasis: A Feasibility Study. COPD. 2020;17(2):184–190.


Dr Dora Triché

Dr Dora Triché (co-chair) works at Nuremberg General Hospital in Germany. Her centre was involved in the randomised controlled trial of HFT versus non-invasive ventilation in patients with chronic hypercapnic respiratory failure that demonstrated a benefit for HFT in this patient population.

Prof. Javier Sayas Catalán

Prof. Javier Sayas Catalán
is based at the Universidad Complutense de Madrid in Spain, where he has found that HFT is valuable in the post-COVID setting for ‘tracheostomy weaning,’ for exercise training in patients with COPD and for patients with cystic fibrosis (CF). Due to lack of data in the CF setting, his centre is planning a pilot study of home HFT for hypoxemic CF patients, of which a key outcome will be lung clearance.

Dr Claudia Crimi

Dr Claudia Crimi is based at the Policlinico San Marco University Hospital in Italy where she has observed the benefits of home HFT in patients with bronchiectasis.

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