ACP issues guidelines on use of high-flow nasal oxygen, point-of-care ultrasound

New guidelines from the College suggest when to use high-flow nasal oxygen rather than noninvasive ventilation or conventional oxygen therapy and address the use of point-of-care ultrasound in ED and inpatient diagnostic pathways for acute dyspnea.

On April 27, ACP issued new guidelines on the use of high-flow nasal oxygen (HFNO) and point-of-care ultrasound (POCUS) in hospitalized patients.

The HFNO guideline, published by Annals of Internal Medicine, includes two specific recommendations:

  • ACP suggests that clinicians use HFNO rather than noninvasive ventilation in hospitalized adults for the management of acute hypoxemic respiratory failure (conditional recommendation).
  • ACP suggests that clinicians use HFNO rather than conventional oxygen therapy for hospitalized adults with postextubation acute hypoxemic respiratory failure (conditional recommendation).

The recommendations were based on an accompanying systematic review of studies comparing HFNO to noninvasive ventilation (n=11) and conventional oxygen therapy (n=21). Compared with noninvasive ventilation, HFNO may reduce rates of all-cause mortality, intubation, and hospital-acquired pneumonia, as well as improving patient comfort, in initial management but not in postextubation management, the review found. The comparison with conventional oxygen showed that HFNO may reduce the risk of reintubation and improve patient comfort after extubation.

In both comparisons, the review authors found that the evidence was of low certainty but that HFNO also appeared to be associated with less harm than the alternative interventions. The review authors also noted that many aspects of HFNO use, including treatment protocols, clinician and health system training, and cost, have yet to be thoroughly studied. “These represent a key part of HFNO utility for a health system,” they wrote. “Broad applicability, including required clinician and health system experience and resource use, remains unknown.”

In the POCUS guideline, also published by Annals, ACP suggests that clinicians may use POCUS in addition to the standard diagnostic pathway when there is diagnostic uncertainty in patients with acute dyspnea in ED or inpatient settings.

This is a conditional recommendation, based on low-certainty evidence. An accompanying evidence report reviewed five randomized controlled trials and 44 prospective cohort-type studies of POCUS for dyspnea. It found that adding POCUS to a standard diagnostic pathway led to more correct diagnoses in patients with dyspnea. POCUS improved the sensitivity of standard diagnostic pathways for congestive heart failure, pneumonia, pulmonary embolism, pleural effusion, and pneumothorax. In-hospital mortality and length of hospital stay did not differ significantly by whether patients received POCUS or not. “Adequate and standardized training for clinicians who use POCUS will be paramount to utilize the benefits of this new technology,” the authors noted.