High-flow nasal oxygen in the perioperative setting: A narrative review

High-flow nasal oxygen (HFNO) has emerged as a valuable tool in perioperative respiratory management, extending its indications beyond intensive care. By delivering heated and humidified oxygen at high flow rates and a precise fraction of inspired oxygen, HFNO improves oxygenation through physiological mechanisms such as dead space washout, generation of low-level positive airway pressure, and reduction of inspiratory effort. Increasing evidence supports its use during multiple perioperative phases, including preoxygenation and apnoeic oxygenation for airway management, prevention of postoperative hypoxaemia, and respiratory support following major surgery. Compared with conventional oxygen therapy, HFNO prolongs safe apnoea time and decreases the incidence of desaturation, especially in high-risk populations such as obese and cardiothoracic surgical patients. In the postoperative period, it may reduce the need for escalation to non-invasive ventilation and improve patient comfort. Moreover, HFNO enhances safety during procedural sedation, such as endoscopy and bronchoscopy, by limiting hypoxaemic events. However, limitations remain, including variability in flow titration, modest and flow-dependent positive end-expiratory pressure generation, and heterogeneity among clinical studies. Future research should focus on defining optimal patient selection, standardising flow settings, and integrating HFNO into personalised perioperative oxygenation strategies. Overall, HFNO represents a well-tolerated, physiologically sound, and clinically valuable option for oxygen delivery throughout the perioperative continuum.