High-Flow Nasal Cannula Therapy in Do-Not-Intubate Patients With Hypoxemic Respiratory Distress

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High-Flow Nasal Cannula in Acute Hypoxemic Respiratory Failure: A Review of the FLORALI Trial

High-Flow Oxygen through Nasal Cannula in Acute Hypoxemic Respiratory Failure

I first shared this article in June of 2019 on Instagram when my account had a mere 2500 followers. Since then the amount of followers to my account have skyrocketed and I could not have done it without the help of each and every one of you who find value in what I do.
As an aside, many of you know I'm preparing a lecture on high-flow nasal cannula and non-invasive ventilation. This article is one of the landmark trials in the HFNC literature and it's worth revisiting in greater detail. After all, I wasn't taking articles apart in as much depth several months ago as I am now. The name by which this study is commonly referred to is the FLORALI trial, as in high FLow Oxygen therapy in Resuscitation of patients with Acute Lung Injury. Witty, huh? The authors had noted that there weren't any studies looking at non-invasive ventilation in patients who were in acute hypoxemic respiratory failure that were not hypercapnic. They went ahead to detail all the beneficial effects of HFNC which I have beat you all over the head with on this medium. They went ahead and designed a prospective, multicenter, randomized, controlled trial to see which worked best to avoid intubations and improve outcomes in patients who were in hypoxemic respiratory failure: NIV, HFNC, or standard oxygen therapy which I will herein refer to as SOT.
They chose to enroll patients who were sick, but not too sick. After all, you need to enroll patients and keep them safe at the same time. If you choose patients who are too sick, then clinicians aren't going to follow the study protocol. They had a strict protocol as well to intubate patients so that patients wouldn't be left lingering without being intubated. After all, there is clear data that if you wait too long to intubate, patients do poorly and there is increased mortality. They included patients who were hypoxemic with a PF ratio < 300, needing a flow of 10L, a PaCO2 < 45 (so no COPD exacerbation patients here) and no chronic respiratory failure. Asthmatics were also excluded, as well as cardiogenic pulmonary edema, use of vasopressors, and hemodynamic instability. They had other parameters but you can check out the article for yourself.
Patients were randomized at 1:1:1 for SOT (nonrebreather at flow of 10L), HFNC (50L of flow and FiO2 titrated), and NIV (pressure support titrated to obtain a tidal volume of 7-10cc/kg ideal body weight and a PEEP between 2-10cmH2O).
When you look at the characteristics of the patients enrolled, and they enrolled 310 of them, the vast majority had pneumonia with a predominance of community acquired followed by healthcare associated pneumonia.
The primary outcome was rates of intubation. There was no difference if you just look at the direct comparison p-value of 0.18. When you look at the patients who had a PF ratio less than 200, though, the patients with HFNC did MUCH better with p-value of 0.009. This is your indication, team! You have someone with pneumonia, don't put the on NIV when HFNC may work better!
Fewer patients died in the ICU if they were to receive HFNC versus the other two (p=0.047).
There was also improved 90 day survival in the HFNC group (p=0.02). This was enough info, and more in the article that you really should read for yourself, to convince many ED and ICU practitioners that HFNC is the way to go in this patient population. Check the article out for yourself!

- EJ





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Frat JP, Thille AW, Mercat A, Girault C, Ragot S, Perbet S, et al.; FLORALI Study Group; REVA Network. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med 2015;372:2185–2196.

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.