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High Flow Nasal Cannula as a treatment for Obstructive Sleep Apnea

David Willms, MD FCCP FCCM


Obstructive sleep apnea (OSA) is a common chronic sleep disorder which often requires prolonged care. Using fairly stringent criteria for diagnosis, estimated prevalence of OSA in the United States is around 15%.(1,2) Weight loss and nocturnal nasal continuous positive airway pressure (CPAP) are the mainstays of therapy for OSA.(3) Unfortunately, adherence with nasal CPAP can be very low, with estimates of non-adherence running as high as 46-83%.(4) Alternative therapies, such as oral appliances, upper airway surgery, and hypoglossal nerve stimulation, are applicable only to a minority of patients affected with OSA. Therefore, many people affected with sleep apnea experience either suboptimal, or no effective treatment for their condition, leading to multiple comorbidities associated with sleep-disordered breathing.

Heated humidified high flow nasal cannula therapy (HFNC), with or without enriched oxygen, has emerged in recent years to become a valuable approach for managing many patients with acute and chronic forms of respiratory therapy.(5) Delivery of higher flow rates of oxygen to the upper airway causes less entrainment of room air during inspiration, resulting in higher delivered fraction of inspired oxygen (FiO2). Also, HFNC flushes the upper airway dead space, enhancing ventilatory efficiency and reducing work of breathing. HFNC, even with room air, generates a positive end-expiratory pressure (PEEP), which may improve airway patency, and reduce the inspiratory work of triggering breaths in obstructed patients, as well as improving lung inflation and oxygenation via a PEEP (positive end-expiratory pressure) effect.(5)

The physiologic and clinical benefits of HFNC have led several clinicians and investigators to trial the use of HFNC in patients with OSA.(6) Small case series, in children(7,8,9) and in adults (10,11,12) have shown clinically important benefits, including reductions in apnea hypopnea index (AHI), and indices of nocturnal oxygen desaturation. On the other hand, analysis of reports of low-flow oxygen in OSA indicates mixed results, with some beneficial effect on oxygen desaturation, but little positive impact on AHI, and even seemed to increase the duration of apnea-hypopnea events.(13)

McGinley et al studied the effect of warm humidified air at 20 liters per minute (L/min) administered to 10 children with OSA.(7) Treatment resulted in improved oxygenation, reduced arousals, and reduction in AHI comparable with that seen with CPAP. Joseph et al also studied HFNC at 5-10 L/min in 5 children with OSA.8 Findings were a reduction in AHI and nadir oxygen saturation. Hawkins et al administered HFNC at 10-50 L/min (6 of 10 were on room air) to 10 children with OSA and CPAP intolerance.(9) Once again, they demonstrated improvement in sleep parameters, including reduction in OHI, and improvement in mean oxygen saturation and in saturation nadir.

In adults, McGinley et al reported use of warm humidified air via HFNC in 11 subjects with OSA.(12) Treatment resulted in reduction in AHI and the respiratory arousal index. A subset of subjects had pharyngeal pressure and ventilation measured, and the mechanism of effect appeared to be related to elevation of end-expiratory pharyngeal pressure. Perlstrom et al studied use of HFNC air at 15-35 L/min in 20 adults with OSA.(11) They demonstrated a mean 50% reduction in AHI. Individual case reports have also shown the potential usefulness of HFNC in disease-associated sleep-disordered breathing, as in acute stroke(14) and chronic obstructive pulmonary disease.(15)

Long-term care for OSA necessarily occurs primarily in the home. At present, most clinical use of HFNC therapy is in the acute care hospital, emergency department, and ICUs. However, several case reports, and recent series have shown the feasibility of using HFNC therapy in the home setting.(8,10,15,16,17,18) For this therapy to achieve widespread acceptance outside the hospital, the technology will need to be adapted for simplicity, safety, and affordability.

In summary, HFNC therapy has physiologic benefits in patients with respiratory disease, including improvements in oxygenation, flushing of nasopharyngeal dead space with resultant effect on ventilation efficiency, and application of end-expiratory pharyngeal pressure. These effects have led to study in patients with OSA, with reported clinically useful benefits. Further study will no doubt elucidate the specific roles for HFNC in OSA, and its future use in the home setting in these patients.


References:


1. Young T, Palta M, Dempsey J, Peppard PE, Nieto FJ, Hia KM. Burden of sleep apnea: rationale, design and major findings of the Wisconsin Sleep Cohort study. WMJ 2009; 108(5):246

2. Peppard PE, Young T, Barnet JH, Palta M, Hagen EW, Hia KM. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol 2013; 177(9):1006

3. Chirinos JA, Gurubhagavatula I, Teff K, Rader DJ, Wadden TA, Townsend R, Foster GD, Maislin G, Saif H, Broderick P, Chittams J, Hanlon AL, Pack AI. CPAP, weight loss, or both for obstructive sleep apnea. N Engl J Med 2014; 370(24):2265

4. Weaver TE, Grunstein RR. Adherence to continuous positive airway pressure therapy: the challenge to effective treatment. Proc Am Thorac Soc 2008; 5(2):173

5. Spoletini G, Alotaibi M, Blasi F, Hill NS. Heated humidified high-flow oxygen in adults: mechanisms of action and clinical implications. Chest 2015; 148(1):1378

6. Diaz-Lobato S, Galarza-Jimenez, Barbero-Herranz E, Mayoralas-Alises S. High flow nasal cannula could be a therapeutic approach to sleep apnea syndrome – current evidences. Gen Med (Los Angel) 2015; 3:6

7. McGinley B, Halbower A, Schwartz AR, Smith PL, Patil SP, Schneider H. Effects of a high-flow open nasal cannula system on obstructive sleep apnea in children. Pediatrics 2009; 124:179

8. Joseph L, Goldberg S, Shitri M, Picard E. High-flow nasal cannula therapy for obstructive sleep apnea in children. J Clin Sleep Med 2015; 11:1007


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