Epstein, A.S., Hartridge-Lambert, S.K., Ramaker, J.S., Voigt, L.P., & Portlock, C.S. (2011). Humidified high-flow nasal oxygen utilization in patients with cancer at Memorial Sloan-Kettering Cancer Center. Journal of Palliative Medicine, 14, 835–839. 

To understand the prevalence of humidified high-flow nasal oxygen (HHFNOx) use at the authors’ institution, and to investigate characteristics related to HHFNOx initiation, discontinuation, and consistency with patient goals of care

In this retrospective study, the characteristics of HHFNOx—Optiflow™—use, including malignancy diagnosis, underlying cardiopulmonary disease, reason for HHFNOx initiation (hypoxia/dyspnea), duration of HHFNOx therapy, reported HHFNOx impact, reason for discontinuation (stable, declined, or expired), and patient outcome were analyzed (discharge/code status). Patients who used the HHFNOx device—Optiflow™—since 2008 were identified via the institution’s database search. Of the 353 patients identified, 183 were randomly selected for analysis. Objective (documented patient comfort and SaO2 on the device, and “step up” and “step down” grading to other oxygen support devices) and subjective (recorded patient and clinician impressions of tolerability) outcomes, oxygen saturation (SaO2), and oxygen interventions pre and post HHFNOx were examined.

• N = 183   
• MEDIAN AGE = 67 years
• AGE RANGE = 20–95 years
• MALES: Not specified, FEMALES: Not specified
• CURRENT TREATMENT: Not applicable
• KEY DISEASE CHARACTERISTICS: The population includes the following malignancies: hematologic (29%), lung (17%), gastrointestinal (15%), sarcoma (6%), head/neck/CNS tumors (5%), breast (4%), and other tumors (24%)
• OTHER KEY SAMPLE CHARACTERISTICS: HHFNOx was used in the intensive care unit (ICU) in 72% of cases and otherwise in the hospital ward alone or in the post-ICU stay.

• SITE: Single site   
• SETTING TYPE: Inpatient    
• LOCATION: Memorial Sloan Kettering Cancer Center in New York, NY

• PHASE OF CARE: Multiple phases of care
• APPLICATIONS: Palliative care 

• Retrospective

• Oxygen saturation (SaO2) percentile range subsets (e.g., 60s, 70s, and so forth)
• Recorded patient and clinician impressions of tolerability to HHFNOx
• Documented SaO2 
• “Step up” and “step down” grading to other oxygen support devices
• Documented reasons for initiation or discontinuation of HHFNOx
• Documented outcome (discharge, vitals, code status)

• Forty-one percent improved while on HHFNOx, 44% remained stable, and 15% declined.
• Subjective reports by the patients were well-documented as well as tolerated with seldom complaints.
• The majority (66%) of patients appeared to benefit indirectly from HHFNOx as it acted as a “step up” or “step down” device between more intensive or invasive forms of ventilation and lower oxygenation.
• Recorded pre-and post-HHFNOx saturations were maintained within the normal range of 90%–100% SaO2.
• At time of data abstraction, 44% of patients were alive, 33% died at the institution, and 22% died outside the institution. 
• Median time of HHFNOx was three days (range = 1–27 days).
• The majority of patients with DNR status pre (12%) or post (43%) HHFNOx died at the institution (78%).
• Full-code status patients (82%) were discharged either to home (82%) or to an outside facility (11%).

HHFNOx was effective in the stabilization or improvement of oxygen saturation in the majority of treated patients. Though HHFNOx devices are expensive, they are a more cost-effective oxygen delivery alternative because they may help prevent escalation to more invasive oxygenation (e.g., mechanical ventilation).

• Risk of bias (no control group)
• Risk of bias (no random assignment)
• Risk of bias (sample characteristics)
• Key sample group differences that could influence results
• The sample included patients with differing goals of care (e.g., curative versus palliative) which would have affected interpretation of effectiveness of the intervention. Distinction between treatment intents are, therefore, not clearly defined because of the limitation of the retrospective design of the study. No data recorded on oxygen support devices after discharge limits the understanding of the role of HHFNOx in discharge planning. Reporting and scoring of dyspnea were not available and, therefore, limits the ability to compare with other studies examining dyspnea and other symptoms. No measurement or report of symptoms of dyspnea exist.

HHFNOx seems well tolerated by various malignancies and clinical trajectories and generally safe. The study claims to be the only clinical description of HHFNOx device used exclusively in the cancer population. Users were able to benefit from high flow of oxygen delivery while still being able to eat and drink (as opposed to oxygen delivery via face mask or face tent).