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High-flow Prong Nasal: Responding to the Risk of COVID-19

A variety of novel and unconventional strategies are constantly emerging to combat the SARS-CoV-2 virus (COVID-19). The recent innovative reaction is the use of high-flow prong nasal (HFPN) in adult patients with COVID-19 respiratory involvement. Compared to traditional oxygen therapy, HFPN provides warm and humidified oxygen at a higher ratio of inspired oxygen levels and flow rates, potentially reducing the number of patients requiring intubation and mechanical ventilation. Increasing the use of HFPN is due to an attempt to mitigate the destructive effects of the virus on the lungs, including pneumonia inflammation that leads to scarring and respiratory system damage that persists after viral treatment.


Benefits of HFPN


Moistening airways by warming and humidifying not only improves oxygenation, but HFPN also provides many respiratory benefits. It reduces the workload of the heart and lungs, directly reducing the production of carbon dioxide. It reduces dead space in the lungs by increasing the surface area available for gas diffusion and providing positive airway pressure. Additionally, HFPN reduces heat consumption by reducing inspiratory effort, increasing lung compliance, and increasing mucous and cilia function, thus helping to reduce the body's energy workload. When the oxygen flow rate is maintained at the highest level tolerable by the patient, the low-level positive pressure produced by HFPN increases lung capacity and improves gas exchange.


Clinical studies have shown that compared to standard masks or non-rebreather masks, patients using HFPN have a higher acceptance and comfort level. This may be due to the ability to eat, drink, and talk more easily. HFPN can also reduce some patients' claustrophobia when wearing a mask.


Correct installation of prong nasal


Correctly installed sheaths can reduce facial pressure damage and the risk of healthcare workers coming into contact with aerosolized virus particles. Insert the cannula fully into the patient's nostrils, and secure it to the patient's head with an elastic band to prevent lateral air escape. Ensure that the strap around the head does not exceed the patient's ears and adjust it to fit the head without being too tight; the headgear should be securely attached to the prong nasal.


The nasal tip diameter should be about half the size of the patient's nostrils to reduce air leakage and the risk of losing positive airway pressure and potential virus aerosolization. Preparing small adult/child and adult size nasal tubes will help ensure a proper fit. Keep the patient in a semi-Fowler position and use periodic prone positioning to help expand the lungs and redistribute lung blood flow to increase perfusion. Ensure that suction devices are easy to use and teach patients to practice coughing and deep breathing to clear the lungs.


Patient monitoring and evaluation of prong nasal


The patients with HFPN are most concerned about the need for emergency intubation if the treatment fails, so it is crucial to identify changes in patients' conditions early. Track trends in vital signs and look for any increased respiratory effort (increase in heart rate, respiratory rate, blood pressure changes, and decreased blood oxygen saturation). Titrate oxygen flow rate based on the patient's respiratory rate and respiratory effort to achieve a target oxygen saturation of no more than 96% or according to facility protocols. Monitor potential respiratory damage to patients, such as decreased oxygen saturation (measured by pulse oximeter), shortness of breath, use of accessory muscles, intercostal retraction, abdominal distension, luminal secretions, and changes in lung sounds. Measure arterial blood gas daily and observe FiO2 titration or changes in patient status. Explain and report the results immediately to the provider.


The American Heart Association recommends that providers assess patients one hour and three hours after starting HFPN to determine the response and whether intubation should be considered. If the patient does not improve, intubation should not be delayed.

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