Authors: Ameya Pappu et al.
Anesthesia & Analgesia 141(4):740–747, October 2025. DOI: 10.1213/ANE.0000000000007424
This Society of Anesthesia and Sleep Medicine opinion paper reviews the rationale and current evidence for using high-flow nasal oxygen (HFNO) in the early postoperative period for patients with sleep-disordered breathing (SDB). HFNO can improve oxygenation, provide low-level positive airway pressure (≈ up to 5 cm H2O at 60 L/min), reduce anatomical dead space, and deliver warmed, humidified gas that enhances comfort and tolerance. While evidence supports HFNO for acute hypoxemic respiratory failure and in some postextubation/cardiothoracic surgery settings, data specifically targeting postoperative SDB remain sparse. Small randomized work suggests HFNO may be better tolerated than CPAP on the first postoperative night, but clinical outcome differences are unclear due to limited sample sizes.
Guideline bodies (ACP, ERS, ESICM, AARC, WHO and others) mostly issue conditional or population-specific recommendations for hypoxemic respiratory failure, with little direct guidance for immediate postoperative SDB. The paper highlights a research agenda: define optimal timing (early vs late), flow/FiO2 protocols, head-to-head comparisons with CPAP/BPAP, long-term outcomes, cost-effectiveness, and patient-centered measures of comfort and adherence.
Potential pitfalls include masking hypoventilation (SpO2 may improve while CO2 rises), uncertain effects on CO2 kinetics, theoretical gastric distension from positive pressure, and special caution in patients with raised intracranial pressure, pulmonary hypertension, COPD with hypercapnia, or those on GLP-1 agonists due to delayed gastric emptying.
What You Should Know
• Use case: Consider HFNO as a well-tolerated oxygenation strategy for postoperative SDB patients who desaturate early, are CPAP-intolerant, or are high-risk (eg, obesity), while recognizing evidence gaps specific to this population.
• Monitoring: Continuous pulse oximetry is essential; add ventilation monitoring (capnography/ABGs) when feasible to avoid masking hypercapnia.
• Modality selection: CPAP/BPAP remains preferred for hypercapnic COPD or when extubation failure risk is high; HFNO can be a reasonable alternative where tolerance limits CPAP.
• Protocol basics: Early initiation (within 24 hours) may be biologically plausible; titrate flows/FiO2 to targets, ensure humidification, and reassess frequently.
• Safety notes: Watch for rising CO2, abdominal distension/aspiration risk, and hemodynamic instability; escalate to NIV or intubation per standard criteria.
• Evidence horizon: Expect future studies to clarify timing, patient selection, outcomes, and economics in the immediate postoperative SDB setting.
Thank you to Anesthesia & Analgesia for advancing discussion on postoperative HFNO for patients with sleep-disordered breathing.