What is this “high flow oxygen at home”?

[FolksBtrippin, BSN, RN]

I’ve been a hospice case manager for 6 months. Before that, I was in psych. 

I have a patient who is on 18L of “high flow” O2 nasal cannula. It’s set up as 2 concentrators; one has a humidifier and one doesn’t. They’re both on 9 liters (or one is 10 and one is 8 that was the other scenario). Small tubing comes out of each concentrator and then connects together and then to tubing that leads to the nasal cannula. 

Is this normal? My pt seems reasonably comfortable and SpO2 96, but I can’t understand how in the world this is a thing. 

No mask. I thought that you could only go up to 4L with regular nasal cannula?

Help me understand. 

[Rose_Queen, BSN, MSN, RN]

Does the patient have regular nasal cannula tubing or true high flow nasal cannula tubing? High flow can do up to 60L.

Here's a study on home high flow O2 use in COPD patients.

[FolksBtrippin, BSN, RN]

It’s regular nasal cannula.

[NRSKarenRN, BSN, RN]

2018:

High-flow Nasal Cannula: Mechanisms of Action and Adult and Pediatric Indications

Quote

This article describes the mechanism of action in an easy to remember mnemonic (HIFLOW); Heated and humidified, meets Inspiratory demands, increases Functional residual capacity (FRC), Lighter, minimizes Oxygen dilution, and Washout of pharyngeal dead space. We will also examine some of the main indications for its use in both the adult and pediatric age groups. The data for the use of high-flow nasal cannula is growing, and currently, some of the main adult indications include hypoxemic respiratory failure due to pneumonia, post-extubation, pre-oxygenation prior to intubation, acute pulmonary edema, and use in patients who are "do not resuscitate or intubate". The main pediatric indication is in infants with bronchiolitis, but other indications are being studied, such as its use in asthma, croup, pneumonia, transport of a critically ill child, and post-extubation.

 

High-Flow Nasal Cannula Oxygen Therapy in Palliative Care

Quote

Background     High-flow nasal cannula (HFNC) oxygen therapy is a relatively new technology for treating hypoxemic respiratory failure and dyspnea.  It can be used as an alternative in select patients who do not desire invasive ventilation or are intolerant to non-invasive ventilation.

Equipment     The HFNC oxygen system consists of an air-oxygen blender, flow meter, heated humidifier, heated circuit, and nasal prongs, all of which are configured to deliver up to 60 L/min of humidified air flow (1). The air-oxygen blender allows precise delivery of fraction of inspired oxygen (FiO2) ranging from 0.21-1.....

2018: High Flow Nasal Cannula (HFNC) – Part 1: How It Works

High Flow Nasal Cannula (HFNC) – Part 2: Adult & Pediatric Indications

2020  The American Nurse: High-flow nasal cannulas: Risks and benefits in response to COVID-19

In my experience, home oxygen concentrators come in 2 types:

a. Delivers 1-4L oxygen

b. Delivers 4-10L oxygen.

High flow @ home may require two 10L oxygen concentrators to reach desired oxygen flow --connected together to one patient output.

High flow nasal cannula (HFNC) is a nasal cannula but it is not a "standard nasal cannula". It has a larger diameter tubing and the prongs that go into the nares are also larger.  High flow is considered for oxygen at 15 liters a minute or greater. 

For persons needing less than 10 liters Oxygen, an Oximizer tubing may be helpful as it helps to concentrate O2 -storing oxygen during exhalation and delivering an enriched bolus in addition to continuous flow upon inhalation, the Oxymizer® requires less oxygen than a standard cannula.  Two types below:

 

 

My husband was on 8-10L O2  HFNC at home due to end stage Pulmonary HTN with R side heart failure -- kept him going for 2 additional years.  ONE portable oxygen tank only lasted 40 min on 10 Liters so I transported 4-5 tanks going to see physicians. After Feb 2018 hospitalization, transitioned to using a Trilogy vent when leaving home for physicians visit whose battery lasted 4-5 hours, could be plugged into car lighter for power and only needed 2  Oxygen tanks for 4hr trip --including stopping at dinner for late lunch.  

Hope this info helped you.

[barcode120x, RN, NP]

On 10/28/2022 at 6:19 PM, FolksBtrippin said:

Is this normal? My pt seems reasonably comfortable and SpO2 96, but I can’t understand how in the world this is a thing. 

No mask. I thought that you could only go up to 4L with regular nasal cannula?

Some of the other posters did post some good info. You can kind of think hierarchy of oxygen devices as: nasal cannula, simple mask, non-rebreather, high flow nasal cannula (HFNC for short), bipap, then lastly, ventilator. The nasal canula can go up to 6 liters before you move up the chain.

On my telemetry floor, we didn't see HFNC too often prior to COVID. Any respiratory patients that needed the "extra O2" were placed on bipap at that time, but we started to see an increase just before COVID hit. Throughout COVID, it was the mainstay of oxygen delivery devices to most of the sick COVID patients because well, to put it bluntly, I was the only device that literally could help our patients breath on there own without having to put a tube down their throat. It was very rare to see a patient go home with a HFNC/bipap machine order even throughout the chaos. My guess it's probably to do with insurance. Whichever the case, going home with either of these intense devices can likely mean the patient prognosis is not that good.

[NurseDeltaInk, RN]

Great info above but my question is why is a hospice patient on such a high liter flow? Are they an early hospice admission and are still interacting with their support persons/upright/eating/toileting themselves, etc? Or are they nearing the end of life? My experience in hospice is that this intervention, at the end of life, is prolonging life and breathlessness can be managed with morphine and an anxiolytic like Ativan. Thank you for being in hospice. It’s a special calling. 

[londonflo]

On 11/4/2022 at 2:18 PM, NurseDeltaInk said:

My experience in hospice is that this intervention, at the end of life, is prolonging life

I thought the point of hospice was to promote quality time with those they love.

On 11/4/2022 at 2:18 PM, NurseDeltaInk said:

breathlessness can be managed with morphine and an anxiolytic like Ativan.

And not drug them up so that family/patient interactions may be difficult. 

[barcode120x, RN, NP]

1 hour ago, londonflo said:

I thought the point of hospice was to promote quality time with those they love.

And not drug them up so that family/patient interactions may be difficult. 

Promoting quality of time is part of hospice, but it's also just as important to ease the suffering of the patient (whether it's pain, GI symptoms, etc). Treating a condition requires an interdisciplinary approach with an ever changing treatment plan. End of life care and suffering can be seen as the same way (assuming those are the wishes of the patient and/or loved ones). There is no fine line on what the best course of action which is why there is the palliative and hospice specialties.

[londonflo]

1 hour ago, barcode120x said:

Promoting quality of time is part of hospice, but it's also just as important to ease the suffering of the patient (whether it's pain, GI symptoms, etc).

I know the rationale/motivation of hospice care. You did not answer my question as to why replace Oxygen (supplemental) requirements with MSo4 and Ativan? Does adding drugs MSO4 and Ativan "ease the suffering of the patient" instead what the actual need of oxygen supplementation will provide?

[londonflo]

2 hours ago, barcode120x said:

Treating a condition requires an interdisciplinary approach with an ever changing treatment plan. End of life care and suffering can be seen as the same way (assuming those are the wishes of the patient and/or loved ones). There is no fine line on what the best course of action which is why there is the palliative and hospice specialties.

I did not realize this area is new to you.

I have been in hospice care for decades. Please don't fall into the trap that a "doped up patient" is easier for the family to deal with.  Long standing family problems really become apparent in a hospice situation.  For those family members that have life long communication problems with the patient, they will look for a way to dodge any exposed feelings with the patient. Heavy/in between/light sedition can be the answer to their prayers.

And after the patient dies, they will praise you to the max! 

[NurseDeltaInk, RN]

22 hours ago, londonflo said:

I thought the point of hospice was to promote quality time with those they love.

And not drug them up so that family/patient interactions may be difficult. 

Each hospice patient/family is unique. Each care plan and end of life wishes are unique and can change hourly. Excellent communication with all involved is paramount. Your comments make hospice nursing seem black and white. It never is.

I initially asked the author of the OP to clarify where in the dying process the patient was at. If they are what we call an “early admission” and still interactive with their environment, high O2 could be seen as an appropriate intervention to promote quality of life and give more time with loved ones while they are still relatively stable. I have not seen that high of liter flow in the home setting but interventions can vary hospice to hospice, medical director to medical director. 

On the other hand, if they are transitioning into the ‘early dying phase,’ this high liter flow is most likely extending their life. Again, knowing ahead of time what the patient wants is the basis of what interventions will be implemented. This may be exactly what they want. Patient/family education is crucial and ongoing. 

When the patient becomes obtunded/unconscious as they near death, liter flow is usually decreased and morphine/Ativan initiated/increased. Sometimes, O2 is DC’d all together, per family request and always based on thorough education.

No hospice nurse will “drug up” a patient for convenience. That would be unethical. But sometimes there is a choice to be made. Are symptoms worth the higher level of consciousness? Some patients think so and refuse pain meds/respiratory meds (morphine) for this very reason. As the process continues, more education and conversations happen with patient/family, always discussing the options and outcomes of said options. During transition and active dying, comfort usually wins over.

It’s so difficulty to give answers to hospice questions in a forum setting. Patient wishes, variable end-stage disease symptoms, family dynamics, religious beliefs, past medical traumas…dying and death brings up so much to address within the home.  All of these things cannot be shared on-line. Hospice nursing is an art form. It’s a delicate dance for sure. So glad we’re here talking about it though! So much to learn from each other…

[FolksBtrippin, BSN, RN]

On 11/4/2022 at 3:18 PM, NurseDeltaInk said:

Great info above but my question is why is a hospice patient on such a high liter flow? Are they an early hospice admission and are still interacting with their support persons/upright/eating/toileting themselves, etc? Or are they nearing the end of life? My experience in hospice is that this intervention, at the end of life, is prolonging life and breathlessness can be managed with morphine and an anxiolytic like Ativan. Thank you for being in hospice. It’s a special calling. 

The short answer is that it’s what the pt and her daughter want.