Pre‐procedure

ActionRationale

1. 1.Show
   Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.
   To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC [198], C).
2. 2.Show
   Decontaminate hands with an alcohol‐based handrub.
   To minimize the risk of healthcare‐associated infection (NHS England and NHSI [179], C).
3. 3.Show
   Assess patient observations and/or National Early Warning Score (NEWS). Perform physical assessment and arterial blood gas (ABG) measurement.
   To determine whether the patient is hypoxaemic (O'Driscoll et al. [209], C) and whether high‐flow oxygen via a nasal cannula (HFN oxygen) is indicated.
4. 4.Show
   Document patient observations/NEWS prior to commencing HFN oxygen.
   To provide baseline observations/NEWS. E
5. 5.Show
   Ensure the patient is sitting upright and in a comfortable position, e.g. the Fowler position (Figure 12.9).
   To promote comfort and aid lung expansion. E

Procedure

1. 6.Show
   Set up HFN oxygen as per the manufacturer's instructions, and attach a sterile water bag to water the humidification chamber.
   Adhering to the manufacturer's guidelines ensures the safe and correct use of equipment. E
2. 7.Show
   Turn the system on and allow it to reach the optimum temperature (37°C).
   To warm the water in the chamber. E
3. 8.Show
   Correctly place the nasal cannula onto the patient and tighten the straps around the patient's head.
   To ensure the fit is snug and comfortable. An ill‐fitting cannula may result in poor oxygenation. E
4. 9.Show
   Monitor the patient's condition and observations/NEWS for the first 5 minutes after HFN oxygen is commenced.
   To detect any deterioration in the patient's condition (O'Driscoll et al. [209], C).
5. 10.Show
   Titrate up the oxygen concentration.
   To achieve target saturations of 94–98% (or 88–92% if the patient is at risk of hypercapnic respiratory failure) (O'Driscoll et al. [209], C).
6. 11.Show
   Titrate up the flow rate (L/min).
   Until a reduction in respiratory rate and target saturations is achieved. E
7. 12.Show
   Document the indication for HFN oxygen, the patient's observations/NEWS, the target oxygen saturations, and the set oxygen concentration and flow rate.
   To maintain accurate records (NMC [198], C) and ensure continuity of care.

Post‐procedure

1. 13.Show
   Monitor and document the patient's observations/NEWS 1 hour after commencing HFN oxygen, and a minimum of 4‐hourly thereafter.
   To monitor for signs of clinical deterioration (O'Driscoll et al. [209], C).
2. 14.Show
   Escalate any concerns to an appropriate member of staff (e.g. senior nursing staff, critical care outreach team, medical staff or physiotherapist).
   To prevent patient deterioration (NICE [188], C).
3. 15.Show
   Monitor the patient's response to HFN oxygen and titrate the flow or oxygen concentration to meet the target saturations, or as per senior nursing/medical staff advice.
   To ensure the patient is not being over‐ or under‐oxygenated. E
4. 16.Show
   Check the equipment regularly (e.g. 4‐hourly) to ensure the correct flow and oxygen concentration are being administered.
   To ensure the equipment is working properly and the patient is not being over‐ or under‐oxygenated. E
5. 17.Show
   Check the tubing regularly to ensure it is free from trapped water. If trapped water is found, lift the tubing and drain the water back into the water humidification chamber.
   Trapped water will result in the inaccurate delivery of oxygen. E
6. 18.Show
   Replace the bag of sterile water approximately every 12 hours or as required so that the water humidification chamber does not dry out.
   The delivery of un‐humidified high‐flow oxygen may dry out or damage the patient's airway. E

   Drying out of the water chamber may damage the equipment. E
7. 19.Show
   Replace the HFN oxygen breathing circuit and water humidification system as instructed by the manufacturer (usually once to twice weekly). All parts should be changed more frequently if they are damaged or discoloured.
   To maintain good infection control practice (Fisher & Paykel Healthcare [83], C).