The process of separating patients from the ventilator after prolonged periods of invasive mechanical ventilation typically involves three steps: Firstly, screening the readiness-to-wean criteria, secondly, conducting a spontaneous breathing trial and thirdly, judging whether a patient will be able to maintain ventilation after extubation.
- Extubation of mechanically ventilated patients has been shown to fail in 10%–15% of ICU patients and is even more common in high-risk cases.
- Current international guidelines recommend using NIV to avoid post-extubation respiratory failure among patients at high risk of reintubation.
- High flow nasal oxygen is more practical to apply than NIV and is considered noninferior to NIV in preventing reintubaton in high-risk patients.
- A new, multicenter RCT investigated whether the use of NIV in combination with HFNO is superior to HFNO alone for reducing reintubation rates in high-risk patients.
- Results showed that the use of NIV combined with HFNO led to a significantly lower reintubation rate within 7 days after extubation than the use of HFNO alone.
This decision is particularly challenging and extubation fails in some 10% to 15% of ICU patients (1). In patients considered to be at high risk, the number is even higher (1, 2). As reintubation is associated with very high mortality rates (3, 4), it is important to implement an oxygenation strategy that may lower the risk.
Current international guidelines for clinical practice recommend using noninvasive ventilation (NIV) to avoid post-extubation respiratory failure in those patients considered at high risk (5). NIV can help to reduce the work of breathing for the patient, which often increases following extubation and cannot be managed by the patient’s weakened respiratory muscles. However, NIV is not tolerated by all patients and there is still no large-scale evidence showing that use of NIV significantly reduces the reintubation rate in comparison with standard oxygen. Another technique that is fairly new is high-flow nasal oxygen (HFNO), which can also decrease the patient’s workload and is considered more comfortable than standard oxygen. In small, randomized controlled trials, HFNO has been shown to result in lower reintubation rates than standard oxygen (6). Furthermore, a larger RCT showed that HFNO was noninferior to NIV in preventing reintubation in high-risk patients (7). Being more practical to apply than NIV, HFNO has therefore been chosen by many clinicians as their preferred treatment for those high-risk patients.
A new, multicenter RCT has now investigated whether the use of NIV in combination with HFNO is superior to HFNO alone for reducing reintubation rates in high-risk patients (8). Based on previous studies, those patients older than 65 years or with an underlying chronic cardiac or lung disease were considered to be high risk (5, 9). A total of 641 were included and randomly assigned to the control group (HFNO alone) or the intervention group (HFNO plus NIV). All patients were treated continuously for 48 hours: In the control group with HFNO at 50 l/min and in the intervention group with NIV for at least 12 hours per day and HFNO (also at 50 l/min) in between NIV sessions, which covered the entire night period wherever possible. Treatment was prolonged beyond the 48-hour period if necessary. NIV was performed with an ICU ventilator in NIV mode or a bilevel ventilator in pressure support (PS) mode with a minimum PS level of 5 cmH2O. Positive end-expiratory pressure was between 5 and 10 cmH2O. In both groups, the fraction of inspired oxygen was adjusted to ensure adequate oxygenation with an oxygen saturation of 92% or higher.
The primary outcome was the need for reintubation within 7 days after extubation. There were several secondary outcomes, which included reintubation at 48 hours, 72 hours and until discharge, as well as an episode of post-extubation respiratory failure within 7 days of extubation. Results showed that the use of NIV combined with HFNO led to a significantly lower reintubation rate within 7 days after extubation than the use of HFNO alone (11.8% vs. 18.2% respectively; p = 0.02). These rates were almost exactly as expected based on previous evidence; a fact that serves to reinforce the trial’s external validity. The rates for 48 hours, 72 hours and until discharge were also significantly lower in the intervention group, as was the proportion of patients with post-extubation respiratory failure at 7 days (21% vs. 29%; p = 0.01).
The main limitation of this study is considered to be that the clinicians were not blinded to the assignment of treatment and therefore could have been influenced in their decision about when to reintubate. However, almost all reintubated patients met the pre-specified criteria for reintubation, and the time to reintubation and mortality rates were similar in both groups. In fact, these two parameters were somewhat higher in the HFNO group. The high mortality rate of greater than 30% also indicates the severity of those patients who were reintubated.
The results of this trial indicate that patients at high risk of extubation failure may benefit significantly from the use of HFNO in combination with NIV, as opposed to HFNO alone. However, authors of a subsequent editorial note the “inconvenience” of this oxygenation strategy (10): While the application of HFNO is comfortable for both patient and clinician, the combination with NIV requires more equipment and can limit both mobilization and communication. Hamilton Medical ventilators offer both a noninvasive ventilation mode as well as an integrated high flow oxygen therapy mode*, enabling you to switch between the two with a minimum of time and effort. In just a few steps, you can change the interface and use the same device and breathing circuit to apply either treatment. In addition, the turbine-driven HAMILTON-C1/C3/T1/MR1 ventilators operate independently of compressed air and can accompany your patients where and whenever is necessary.
*Optional feature on HAMILTON-G5 and HAMILTON-C1/T1/MR1 ventilators
- 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. doi: 10.1164/rccm.201208-1523CI
- Esteban A, Frutos-Vivar F, Muriel A, et al. Evolution of mortality over time in patients receiving mechanical ventilation. Am J Respir Crit Care Med. 2013;188(2):220-230. doi:10.1164/rccm. 201212-2169OC
- Epstein SK, Ciubotaru RL,Wong JB. Effect of failed extubation on the outcome of mechanical ventilation. Chest. 1997;112(1):186-192. doi:10.1378/ chest.112.1.186
- Frutos-Vivar F, Esteban A, Apezteguia C, et al. Outcome of reintubated patients after scheduled extubation. J Crit Care. 2011;26(5):502-509. doi:10. 1016/j.jcrc.2010.12.015
- Rochwerg B, Brochard L, Elliott MW, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J. 2017;50(2):1602426. doi:10.1183/ 13993003.02426-2016
- Maggiore SM, Idone FA, Vaschetto R, et al. Nasal high-flow versus Venturi mask oxygen therapy after extubation. Effects on oxygenation, comfort, and clinical outcome. Am J Respir Crit Care Med. 2014;190(3):282-288. doi:10.1164/rccm. 201402-0364OC
- Hernández G, Vaquero C, Colinas L, et al. Effect of postextubation high-flow nasal cannula vs noninvasive ventilation on reintubation and postextubation respiratory failure in high-risk patients: a randomized clinical trial. JAMA. 2016;316 (15):1565-1574. doi:10.1001/jama.2016.14194
- Thille AW, Muller G, Gacouin A, et al. HIGH-WEAN Study Group and the REVA Research Network. Effect of postextubation high-flow nasal oxygen with noninvasive ventilation vs high-flow nasal oxygen alone on reintubation in patients at high risk of extubation failure [published online October 2, 2019]. JAMA. doi:10.1001/jama.2019.14901
- Thille AW, Harrois A, Schortgen F, Brun-Buisson C, Brochard L. Outcomes of extubation failure in medical intensive care unit patients. Crit Care Med. 2011;39(12):2612-2618. doi:10.1097/CCM. 0b013e3182282a5a
- Telias I, Ferguson ND. Added Benefit of Noninvasive Ventilation to High-Flow Nasal Oxygen to Prevent Reintubation in Higher-Risk Patients. JAMA. 2019 Oct 2. doi: 10.1001/jama.2019.14609. [Epub ahead of print]
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