In mechanically ventilated patients at high risk for extubation failure, the use of high-flow nasal oxygen with noninvasive ventilation (NIV) immediately after extubation significantly decreases the risk for reintubation compared with high-flow nasal oxygen alone, according to the results of a clinical trial (ClinicalTrials.gov Identifier: NCT03121482) published in the Journal of the American Medical Association.1

Approximately 10% to 15% of patients in the intensive care unit (ICU) who are ready to be separated from a ventilator experience extubation failure leading to reintubation.2 NIV may prevent postextubation respiratory failure in patients at high risk; however, only 2 small studies have demonstrated decreased reintubation rates compared with standard oxygen.3,4

High-flow nasal oxygen is an alternative strategy that may reduce the risk for reintubation compared with standard oxygen; therefore, researchers in France compared high-flow nasal oxygen alone (n=306) with high-flow nasal oxygen and NIV (n=342) in patients at high risk for extubation failure (ie, > aged 65 years or with an underlying cardiac or respiratory disease).1 The researchers found that the reintubation rate at day 7 was 11.8% with high-flow oxygen and NIV and 18.2% with high-flow nasal oxygen alone (P =.02).

In addition, the proportion of patients with postextubation respiratory failure at day 7 and reintubation rates up until ICU discharge were significantly lower with high-flow nasal oxygen and NIV than with high-flow nasal oxygen alone. However, ICU mortality rates were not significantly different between the groups (6% vs 9% in high-flow nasal oxygen and NIV vs high-flow nasal oxygen alone; P =.25).

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“In this multicenter, randomized, open-label trial, high-flow nasal oxygen with noninvasive ventilation, compared with high-flow nasal oxygen alone, decreased the rate of reintubation within the first 7 days after extubation in the ICU,” the authors concluded.1

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

References

1. Thille AW, Muller G, Gacouin A, et al. Effect of postextubation high-flow nasal oxygen with noninvasive ventilation vs high-flow nasal oxygen alone on reintubation among patients at high risk of extubation failure. A randomized clinical trial. JAMA. 2019;322(15):1465-1475.

2. Thille AW, Richard J-CM, Brochard L. The decision to extubate in the intensive care unit. Am J Respir Crit Care Med. 2013;187(12):1294-1302.

3. Ornico SR, Lobo SM, Sanches HS, et al. Noninvasive ventilation immediately after extubation improves weaning outcome after acute respiratory failure: a randomized controlled trial. Crit Care. 2013;17(2):R39.

4. Nava S, Gregoretti C, Fanfulla F, et al. Noninvasive ventilation to prevent respiratory failure after extubation in high-risk patients. Crit Care Med. 2005;33(11):2465-2470.