Feeding practices during high-flow nasal cannula: current evidence and clinical implications for respiratory care

High-flow nasal cannula (HFNC) therapy is increasingly used as a noninvasive respiratory support modality across acute and critical care settings. Although nutritional management is integral to the care of patients with respiratory failure, established guidelines for feeding patients receiving HFNC are lacking, and clinical decisions vary widely, reflecting persistent uncertainty about HFNC's effects on swallowing function, airway protection, and aspiration risk. This narrative review found that HFNC may alter swallowing biomechanics, particularly at flow rates >40 L/min, potentially increasing the risk of choking and aspiration. Evidence on aspiration risk is heterogeneous, deriving largely from healthy volunteers and pediatric bronchiolitis cohorts. Adult evidence is limited to retrospective studies; the largest found no increase in respiratory deterioration with enteral feeding. Most institutions lack formal feeding protocols, and practice is driven by individual clinician judgment. Areas of consensus include the safety of early enteral feeding in hemodynamically stable patients and the avoidance of routine prolonged withholding of nutrition based solely on HFNC use. Disagreement persists regarding routine swallowing assessment, optimal flow thresholds during feeding, and the prioritization of oral versus tube feeding. Safe feeding in patients receiving HFNC requires a multidisciplinary, individualized approach that balances respiratory support against nutritional adequacy. Prospective multicenter studies are needed to define safe flow thresholds, validate bedside assessment tools, and establish standardized feeding guidelines, particularly in adult and critically ill populations.