Background Optiflow therapy (OF) is nasal high flow Oxygen that is hospital based. Its aims are to reduce work of breathing and symptomatic breathlessness. Its use is generally initiated by critical care outreach in order to prevent admissions to critical care for ventilatory support. The concern was that OF was mainly commenced acutely without considering ramifications on achieving Preferred place of care or death (PPC/PPD). Local and National guidance is lacking for patients who are receiving palliative care. We aimed to develop a guideline for initiating OF within the hospital.

Methods A baseline retrospective notes review was conducted. 60 adult medical in-patients who started OF on the wards between October 2018 and October 2019 were included.

Results The most common reason for commencing OF was infection (61%), Pulmonary oedema (13.4%), Pneumonitis (4.9%) and Pleural effusions (4.9%). Most patients remained on OF for less than 4 days (43 patients, 71.7%). OF was initiated in 65% patients out of hours. Most often an MDT was used to make the decision. In 43% patients a ‘ceiling of treatment’ decision was documented prior to starting OF: of these 35% were for full escalation, 35% for inotropes but not intubation and 30% for ward-based treatment only. Prior to starting OF 3% had a PPD documented. The majority of patients 65% improved on OF and were weaned off. However, 82% patients died within 8 (most of those within the first 4) months of initiation of OF; either whilst on OF, later in the admission when stopped OF, or following discharge.

Conclusions The results suggest that although the vast majority of patients are weaned off OF, it does signal a deteriorating patient and referral to palliative care should be initiated. A guideline is being developed to support clinical decision making around the use of OF.