High flow nasal cannula

• Most are not considered reusable per manufacturer specifications 
• Check with the manufacturer specification and clinical guidelines to determine if reuse is safe
• Steps for disinfection must be closely adhered to and may be manufacturer specific 
• Some reusable devices (e.g. some ventilator circuits) may have a finite lifespan (e.g. a predefined number of sterilizing cycles)
• Reusability of respiratory care devices is often debated and may vary based on local/national practice guidelines and regulations   

Click here to review WHO tips for cleaning and disinfection of respiratory equipment 

Additional resources:

• Infection Prevention and Control of Epidemic- and Pandemic-Prone Acute Respiratory Infections in Health Care (WHO)
• Disinfectants for COVID-19 (US EPA)
• Cleaning of CPAP and other devices used to administer supplemental oxygen (DPHSS Montana)
• Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents. G. Kampf, D. Todt,  S. Pfaender, E. Steinmann. Journal of Hospital Infection 104 (2020) 246-251.
• Disinfection and sterilization: an overview. Rutala, Weber. Am J Infect Control
• Disinfectants used for environmental disinfection and new room decontamination technology; Rutala, Weber. Am J Inect Control. 2013
• Guidelines for disinfection and sterilization in healthcare facilities, HICPAC, CDC 2019
• Reuse of anesthesia breathing systems: another difference of opinion and practice between the US and Europe, J Clin Anes 2008
• Bacterial and viral contamination of breathing circuits after extended use – an aspect of patient safety? Acta Anaes Scan, 2016

Any time the patient can cough or sneeze into the room – the  risk of infection is increased.  It is not clear that adding high flow nasal oxygen makes this worse.  However, at a flow of 40-60 lpm if the patient coughs, model studies have shown some additional movement of particles in the room.

Healthcare worker infection from nosocomial transmission of SARS CoV-1was associated with lack of adequate infection control precautions especially in the presence of  aerosol generating procedures. By definition this would also include HFNC. However, the risk of health care worker infection from HFNC was reported to be substantially less (8%) compared to intubation (35%) and NIPPV (38%) (Raboud et al. Plos One 2010). Moreover, placement surgical masks over a HFNC reduces the emission and dispersion of coronavirus bioaerosols (Leung et al. Nat Med 2020)

Use this Oxygen calculator

This is somewhat controversial. 

For short periods of time (hours), NIPPV may be tolerated without humidity, but for longer periods of time (days) humidity is essential, especially at high FIO2 (100% oxygen from a tank or other high pressure source is ~anhydrous). Leaks with NIPPV (around a mask seal) create issues with humidification and is one reason HMEs don’t work well with NIPPV. 

For HFNC, most people find >6LPM NC intolerable without humidification, but with humidification most people don’t notice flow until it exceeds 15LPM and will tolerate >40LPM. With HFNC (and nasal CPAP) gas flow is unidirectional (in the nose and out the mouth) and thus there is no possibility for reclaiming moisture from the exhaled breath. Without heat and humidification most patients will find this intolerable.  

Here is a comparison table by ECRI

(Please reference the manufacturers’ manuals as the accuracy of this table is not guaranteed).

Estimated Fraction of Inspired Oxygen (FiO2)

The values represent estimates of FiO2. Actual FdO2 (delivered O2 concentration) is dependent on multiple factors including oxygen supply quality, patient’s minute ventilation and inspiratory flow rate. One general estimation rule is using oxygen flow rate: FiO2 =0.21 + 0.03 x oxygen flow rate in L/min (Frat et al).

Moisture present in patients’ lungs is rapidly lost at high breathing rates.

When breathing dry air, cilia stop functioning properly (in a matter of hours – Hirsch et al J Appl Physio 1975). When the moisture level becomes low, mucous in the patient’s lungs can become thick and hard, and quickly block the patient’s airways, or the endotracheal tube, stopping airflow. 

Additionally, heat is rapidly lost to non-humidified air.