Oxygenation and ventilation impairment after planned extubation is frequent. Post-extubation respiratory management aims to decrease the risk of early acute respiratory failure and reintubation, which is associated with a poor prognosis (1).
Take away messages
- Two multicenter randomized controlled trials compared the use of high flow oxygen therapy after planned extubation with conventional oxygen therapy and noninvasive ventilation (NIV) respectively
- Reintubation within 72 hours and post-extubation respiratory failure were significantly less common in the high flow than in the conventional oxygen therapy group
- High flow oxygen therapy was not inferior to NIV for preventing reintubation and resulted in a lower rate of post-extubation respiratory failure
- Systematic use of high flow oxygen therapy after planned extubation improves the clinical outcome for all ICU patients in terms of acute respiratory failure and reintubation within 72 hours
Oxygenation and ventilation impairment after planned extubation is frequent. Post-extubation respiratory management aims to decrease the risk of early acute respiratory failure and reintubation, which is associated with a poor prognosis (1). In addition to mobilization and physiotherapy, three non-invasive oxygenation and ventilation support methods may be used in this situation: Conventional oxygen therapy, high flow oxygen therapy, and noninvasive ventilation (NIV) including CPAP and bi-level positive airway pressure. In subgroups of patients with a high risk of post-extubation respiratory failure, preventive use of NIV for 24 hours after planned extubation was associated with a lower reintubation rate (2, 3, 4). High flow oxygen therapy combines several features, including constant FiO2, washout of upper-airway anatomical dead space, optimal gas conditioning, continuous treatment, and the comfort of a nasal cannula, with positive physiological effects such as a low level of PEEP with increased end-expiratory lung volume, lower work of breathing, improved drainage of respiratory secretions, and decreased dyspnea (5, 6). Given that planned extubation is a daily occurrence in the ICU, it is important to establish the role of high flow oxygen therapy in post-extubation respiratory management.
In a multicenter randomized controlled trial, Hernández et al. compared high flow oxygen therapy and conventional oxygen therapy after planned extubation for 527 ICU patients considered at low risk of reintubation (7). Treatment was applied for 24 hours after extubation, and the primary outcome of the study was reintubation within 72 hours. High flow was used at 31±8 l/min with FiO2 set at 32±8%. The rates for reintubation within 72 hours and post-extubation respiratory failure were significantly lower with high flow oxygen therapy than with conventional oxygen therapy (4.9% versus 12.2%, p=.004 and 8.3% versus 14.4%, p=.03 respectively). The time to reintubation, length of the ICU stay and mortality rates did not differ significantly between the two groups.
In a second multicenter randomized controlled trial, the same group of researchers performed a noninferiority study comparing high flow oxygen therapy and NIV after planned extubation for 604 patients considered at high risk of reintubation (8). Treatment was applied for 24 hours after extubation, and the primary outcome of the study was post-extubation respiratory failure and reintubation within 72 hours. High flow was used at 50±5 l/min with FiO2 set at 35% (30%-40%). The rate of post-extubation respiratory failure was significantly lower with high flow oxygen therapy than with NIV (26.9% versus 39.8% respectively; risk difference 12.9%; 95%CI=6.6% to ∞). High flow oxygen therapy was not inferior to NIV in terms of reintubation within 72 hours (22.8% versus 19.1% respectively; risk difference -3.7%; 95%CI=-9.1% to ∞). The time to reintubation was not significantly different between the two groups.
These studies add to the mounting evidence that post-extubation respiratory management may positively impact the clinical outcome in terms of post-extubation respiratory failure and reintubation within 72 hours. High flow oxygen therapy after planned extubation has been shown to benefit all patients mechanically ventilated for more than 12 hours in the ICU, regardless of the risk for reintubation. For patients at high risk, and particularly for those suffering from COPD or obesity who benefit from PEEP or pressure support, high flow oxygen therapy may be alternated with NIV sessions. However, cautious clinical assessment is required for patients still being treated with high flow oxygen therapy 48 hours after extubation, to avoid risking delayed reintubation.
In these studies, high flow oxygen therapy was applied at 37°C with a mean flow rate of 30 and 50 l/min respectively, and FiO2 was adjusted to reach the target SpO2. Ventilators from Hamilton Medical offer high flow oxygen therapy as a standard or optional feature*, with maximum flow rates of up to 80 l/min and FiO2 of between 21% and 100%. There is no additional device or ventilator required; after extubation, the nasal cannula is connected at the Y-piece and high flow oxygen therapy is then activated to start the treatment. The therapy can be alternated with noninvasive ventilation as needed by changing the interface and switching to NIV mode on the ventilator. Used in conjunction with the HAMILTON-H900 humidifier and heated ventilator circuit, Hamilton Medical ventilators provide high flow oxygen therapy with optimally conditioned gas that can be adjusted to the desired temperature.
The systematic use of high flow oxygen therapy after planned extubation decreases the risk of acute respiratory failure and reintubation within 72 hours for all ICU patients.
* Not all features are available in all markets.
- Epstein SK, Ciubotaru RL,Wong JB. Effect of failed extubation on the outcome of mechanical ventilation. Chest 1997; 112(1):186-192.
- Nava S, Gregoretti C, Fanfulla F, Squadrone E, Grassi M, Carlucci A, et al. Noninvasive ventilation to prevent respiratory failure after extubation in high-risk patients. Crit Care Med 2005; 33(11):2465-70 (abstract).
- Ferrer M, Valencia M, Nicolas JM, Bernadich O, Badia JR, Torres A. Early noninvasive ventilation averts extubation failure in patients at risk: a randomized trial. Am J Respir Crit Care Med 2006; 173(2):164-70.
- Thille AW, Boissier F, Ben-Ghezala H, Razazi K, Mekontso-Dessap A, Brun-Buisson C, Brochard L. Easily identified at-risk patients for extubation failure may benefit from noninvasive ventilation: a prospective before-after study. Crit Care 2016; 20:48.
- Maggiore SM, Idone FA, Vaschetto R, Festa R, Cataldo A, Antonicelli F, 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):282-8.
- Mauri T, Turrini C, Eronia N, Grasselli G, Volta CA, Bellani G, Pesenti A. Physiologic Effects of High-flow Nasal Cannula in Acute Hypoxemic Respiratory Failure. Am J Respir Crit Care Med 2017. [Epub ahead of print] (abstract).
- Hernández G, Vaquero C, González P, Subira C, Frutos-Vivar F, Rialp G, et al. Effect of Postextubation High-Flow Nasal Cannula vs Conventional Oxygen Therapy on Reintubation in Low-Risk Patients: A Randomized Clinical Trial. JAMA 2016; 315(13):1354-61.
- Hernández G, Vaquero C, Colinas L, Cuena R, González P, Canabal A, 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.
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