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

Original: JAMA 2019. [Epub ahead of print]

Author(s): Thille AW, Muller G, Gacouin A, Coudroy R, Decavèle M, Sonneville R, Beloncle F, Girault C, Dangers L, Lautrette A, Cabasson S, Rouzé A, Vivier E, Le Meur A, Ricard JD, Razazi K, Barberet G, Lebert C, Ehrmann S, Sabatier C, Bourenne J, Pradel G, Bailly P, Terzi N, Dellamonica J, Lacave G, Danin PÉ, Nanadoumgar H, Gibelin A, Zanre L, Deye N, Demoule A, Maamar A, Nay MA, Robert R, Ragot S, Frat JP; HIGH-WEAN Study Group and REVA Research Network

Reviewer: Claudia Crimi

Published: 07 Nov, 2019

Timely identification of patients at high risk of extubation failure and implementation of appropriate strategies to prevent post-extubation respiratory failure is a crucial issue for ICU (Intensive Care Unit) physicians (1).
International guidelines suggest that Noninvasive Ventilation (NIV) should be used to prevent post-extubation respiratory failure in high-risk patients (2). Furthermore, a recent Randomized Control Trial (RCT) from Hernandez et al. (3) showed that High-Flow Nasal Oxygen (HFNO) is not non-inferior to NIV in preventing re-intubation at 72 hours in patients at high-risk of intubation.
The recent study conducted by Thille et al. examined the best strategy to reduce the risk of re-intubation among high-risk mechanically ventilated patients, comparing two treatment strategies: HFNO + NIV (PS 8±2, PEEP 5±1; first NIV session for > 4h and at least 12 h/day for 48h) and HFNO alone (flow of 50 L/min and FiO2 adjusted for SpO2 > 92%; at least for 48h).
In this multicenter RCT conducted at 30 ICUs in France, 648 adult patients intubated for > 24h and at high risk of extubation failure (> 65 years or with underlying chronic lung or cardiac diseases) were randomized to HFNO + NIV (n = 342) or HFNO alone (n = 306), immediately after extubation. Patients were stratified on PaCO2 level >45 mmHg.
The primary outcome was re-intubation at 7 days; secondary outcomes included post-extubation respiratory failure at day 7, re-intubation rates up until ICU discharge and ICU mortality.

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