High-Flow Nasal Oxygen Therapy for Perioperative Respiratory Optimization and Peri-Oxygenation in Patients with Chronic Cardio-Respiratory Disease: A Comprehensive Evidence Review

Background: Patients with chronic cardio-respiratory diseases face substantially elevated perioperative complication risks. High-flow nasal oxygen (HFNO) therapy has emerged as a promising non-invasive respiratory support modality, yet evidence specific to this high-risk population has not been comprehensively synthesized. Objectives: To systematically evaluate HFNO effectiveness across the perioperative continuum—including pre-oxygenation, apneic oxygenation, and post-extubation support—in patients with chronic obstructive pulmonary disease, heart failure, interstitial lung disease, obesity, and related conditions. We aimed to compare HFNO with alternative modalities and provide evidence-based implementation guidance. Methods: We conducted a comprehensive narrative review with systematic search of major databases including PubMed, Embase, and the Cochrane Library for randomized controlled trials, systematic reviews, and observational studies involving adult patients with chronic cardio-respiratory diseases undergoing surgery with HFNO intervention at any perioperative phase. Quality assessment using established tools was performed with structured narrative synthesis organized by perioperative phase and disease population. Results: The review synthesizes evidence across multiple perioperative applications, comparing HFNO effectiveness with conventional oxygen therapy and non-invasive ventilation. Disease-specific considerations for chronic obstructive pulmonary disease, heart failure, obesity and obstructive sleep apnea, interstitial lung disease, and thoracic surgery populations are delineated. Evidence-based clinical algorithms for patient selection, protocol optimization, and escalation strategies are provided. Cost-effectiveness, implementation barriers, training requirements, and integration into Enhanced Recovery pathways are addressed. Conclusions: HFNO represents a valuable non-pharmacological intervention for perioperative respiratory optimization in chronic cardio-respiratory disease patients. This comprehensive synthesis provides clinicians with evidence-based guidance for implementation while identifying critical research gaps. Proper patient selection and protocol optimization can reduce postoperative pulmonary complications, prevent reintubation, and improve outcomes in this high-risk population. Future research should focus on personalized approaches, long-term outcome assessment, and implementation science. Keywords: High-flow nasal oxygen; HFNO; perioperative care; chronic obstructive pulmonary disease; heart failure; respiratory failure; non-invasive respiratory support; surgical complications; perioxygenation.