INTRODUCTION

Pneumonia, including community-acquired and hospital-acquired forms, is a major cause of acute respiratory deterioration in intensive care and may be complicated by respiratory failure and sepsis [1]. For patients who progress to severe hypoxemia, respiratory support must be individualized and escalated according to clinical response.

Key components of intensive respiratory and resuscitation care in severe pneumonia include lung-protective ventilation with low tidal volumes and limitation of plateau pressure [2], the use of high-flow nasal oxygen or non-invasive ventilation in selected patients with hypoxemia [3], and prone positioning in severe acute respiratory distress syndrome (ARDS) [4]. Sedation should preserve comfort without unnecessarily suppressing spontaneous breathing [5]; agents that allow lighter, more controllable sedation may be useful when clinically appropriate [6]. Hemodynamic stabilization in septic pneumonia requires attention to perfusion targets [7], while fluid balance, early mobilization, and nutritional support are also relevant to recovery [15,18,24], [8], [9].

High-flow therapy (HFT) delivers heated and humidified gas at flow rates that exceed those used in conventional oxygen systems. Terms such as high-flow nasal cannula (HFNC), high-flow nasal oxygen (HFNO), and high-flow oxygen therapy (HFOT) are often used interchangeably, although HFT is a broader technical term [10]. The technology has evolved from early high-flow systems into a widely used form of respiratory support [11], and its current clinical role includes both practical delivery considerations and a range of applications in acute respiratory and critical care [12].

HFNC is generally delivered through a flow generator, an air-oxygen blender, an active heated humidifier, heated tubing, and wide-bore nasal prongs. Its physiological effects are related to washout of upper-airway dead space, reduction of respiratory effort, generation of a modest positive end-expiratory pressure, and changes in tidal and end-expiratory lung volumes. By reducing rebreathing and improving the effective inspired gas mixture, high-flow delivery may improve oxygenation [14]. Positive pressure and high flow can also reduce nasopharyngeal resistance [15], while the degree of end-expiratory pressure varies with flow, interface fit, and whether the mouth is open or closed [16]. Heated humidification improves mucosal tolerance and may facilitate prolonged use of therapy [17]. In acute hypoxemic respiratory failure, these mechanisms can improve oxygen delivery and reduce respiratory workload [18].

Study rationale and objective

The clinical benefit of HFOT depends on consistent bedside implementation: correct device assembly, appropriate flow and FiO₂ titration, monitoring of respiratory status, and timely escalation when treatment is failing. The practical contribution of this study is the simultaneous evaluation of patient-related and process indicators before and after a standardized staff-training program in a real-world multidisciplinary ICU. The objective was to assess whether the training intervention was associated with improved oxygenation and respiratory rate, lower intubation frequency, greater patient comfort, and fewer incorrect HFOT settings.

MATERIALS AND METHODS

Study design and setting

A single-center before-and-after quality improvement study was conducted in the intensive care unit of a multidisciplinary hospital over a six-month period. Baseline performance was recorded during the first three months, followed by a structured educational intervention for staff and reassessment during the subsequent three months.

Participants and clinical context

A total of 100 patients who required HFOT were included during the six-month study period. The training intervention involved 20 nurses and 10 physicians working in the ICU. The available study documentation did not specify the exact numbers of patients in the pre- and post-training periods, detailed inclusion and exclusion criteria, or baseline clinical characteristics; therefore, subgroup and risk-adjusted analyses were not performed.

Training intervention

The intervention combined theoretical instruction with hands-on training. The curriculum covered indications and contraindications for HFOT; device preparation; initial parameter selection; titration of flow and FiO₂; humidification and temperature settings; bedside monitoring; recognition of treatment success or failure; prevention of common complications; and stepwise weaning.

Competency reinforcement

A 10-item nurse questionnaire was used as a structured teaching aid. It addressed indications and contraindications, device preparation, initial settings, target oxygenation, monitoring, criteria of effectiveness, potential complications, and weaning. The questionnaire was used to reinforce a common bedside algorithm rather than as a validated psychometric instrument.

Outcomes and data collection

Five clinical and operational indicators were compared between the pre- and post-training periods: (1) proportion of patients achieving SpO₂ ≥92%; (2) proportion with respiratory rate <25 breaths/min; (3) need for endotracheal intubation; (4) patient-reported discomfort during HFOT; and (5) incorrect device parameter settings.

Statistical approach

Outcomes were summarized as percentages for the pre- and post-training periods. The original statistical analysis reported p-values from a paired t-test. Because the evaluated outcomes are categorical proportions and patient-level pairing and exact phase-specific denominators were not available for independent reanalysis, the reported p-values were retained as source data but were not used as the sole basis for causal inference. Interpretation therefore emphasizes the direction and magnitude of descriptive changes.

Ethical considerations

This work was conducted as an institutional quality-improvement project aimed at standardizing high-flow oxygen therapy in routine intensive care practice. The analysis used routinely collected, de-identified clinical and operational data. No experimental patient-level interventions or procedures beyond standard clinical care were introduced. Under the institutional framework applicable to this quality-improvement activity, separate ethics committee approval and individual informed consent were not required. Patient confidentiality was maintained throughout the project.

RESULTS

Clinical and process indicators

All five indicators changed in a favorable direction after implementation of the staff-training program. The proportion of patients achieving SpO₂ ≥92% increased from 70% to 95%, while the proportion with a respiratory rate <25 breaths/min increased from 65% to 90%. The reported need for intubation decreased from 30% to 10%, patient-reported discomfort from 40% to 15%, and incorrect HFOT parameter settings from 50% to 5%.

Table 1 - Key clinical and operational indicators before and after staff training

The original analysis reported p<0.001 for SpO₂ ≥92% and respiratory rate <25 breaths/min, p=0.002 for need for intubation, p=0.003 for patient-reported discomfort, and p<0.001 for incorrect parameter settings. Because these outcomes are proportions and patient-level paired data were not available, the p-values should be interpreted cautiously.

The main pre- and post-training changes are shown graphically in Figures 1-3.

Figure 1 - Proportion of patients achieving the oxygenation target (SpO₂ ≥92%) and respiratory-rate target

(<25 breaths/min) before and after staff training

Figure 2 - Need for intubation and patient-reported discomfort before and after staff training

Figure 3 - Frequency of incorrect HFOT parameter settings before and after staff training