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BACKGROUND High-flow nasal cannula (HFNC) has become a frequently used non-invasive form of respiratory support in acute settings, however evidence supporting its use has only recently emerged. These guidelines provide evidence-based recommendations for the use of HFNC alongside other noninvasive forms of respiratory support in adults with acute respiratory failure (ARF). MATERIALS AND METHODOLOGY The European Respiratory Society Task Force panel included expert clinicians and methodologists in pulmonology and intensive care medicine. The Task Force used the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) methods to summarise evidence and develop clinical recommendations for the use of HFNC alongside conventional oxygen therapy (COT) and non-invasive ventilation (NIV) for the management of adults in acute settings with ARF. RESULTS The Task Force developed 8 conditional recommendations, suggesting using: 1) HFNC over COT in hypoxemic ARF, 2) HFNC over NIV in hypoxemic ARF, 3)HFNC over COT during breaks from NIV, 4) either HFNC or COT in post-operative patients at low risk of pulmonary complications, 5) either HFNC or NIV in post-operative patients at high risk of pulmonary complications, 6) HFNC over COT in non-surgical patients at low risk of extubation failure, 7) NIV over HFNC for patients at high risk of extubation failure unless there are relative or absolute contraindications to NIV, 8) trialling NIV prior to use of HFNC in patients with chronic obstructive pulmonary disease (COPD) and hypercapnic ARF. CONCLUSIONS HFNC is a valuable intervention in adults with ARF. These conditional recommendations can assist clinicians in choosing the most appropriate form of non-invasive respiratory support to provide to patients in different acute settings.

During the coronavirus disease 2019 (COVID-19) pandemic, noninvasive respiratory support has played a central role in managing patients affected by moderate-to-severe acute hypoxemic respiratory failure, despite inadequate scientific evidence to support its usage. High-flow nasal cannula (HFNC) treatment has gained tremendous popularity because of its effectiveness in delivering a high fraction of humidified oxygen, which improves ventilatory efficiency and the respiratory pattern, as well as its reported high tolerability, ease of use, and application outside of ICUs. Nevertheless, the risk of infection transmission to health-care workers has raised some concerns about its use in the first wave of the pandemic outbreak, with controversial recommendations provided by different scientific societies. This narrative review provides an overview of the recent evidence on the physiologic rationale, risks, and benefits of using HFNC instead of conventional oxygen therapy and other types of noninvasive respiratory support devices, such as continuous positive airway pressure and noninvasive ventilation in patients affected by COVID-19 pneumonia with associated acute hypoxemic respiratory failure. It also summarizes the available evidence with regard to the clinical use of HFNC during the current pandemic and its reported outcomes, and highlights the risks of bioaerosol dispersion associated with HFNC use.