What is the role of high-flow nasal cannula oxygen therapy in postextubation noninvasive ventilation (NIV) support?

Updated: Jun 18, 2020
  • Author: Guy W Soo Hoo, MD, MPH; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
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Answer

High-flow nasal cannula oxygen (HFNC) may have a role in this setting, probably better than face mask oxygen. [32] Its potential benefit may lie in its ability to provide higher levels of oxygen and a small amount of positive pressure compared with standard oxygen therapy. Its performance and role compared with NIV has undergone additional investigation. A randomized, multicenter trial involving 830 patients following cardiothoracic surgery found comparable failure rates (reintubation) between HFNC (21%) compared with NIV provided as BiPAP (21.9%). BiPAP-randomized patients had a higher PaO2/FIO2 than HFNC patients, but no differences were noted in a host of secondary outcome measures, including PaCO2, pH, respiratory rate, dyspnea score, comfort score, nosocomial pneumonia, pneumothorax, and length of stay in the ICU or hospital. [33]

A prospective randomized trial involving 604 patients with a mix of initial of both medical and surgical diagnoses, including ARDS, decompensated heart failure, and COPD exacerbations, and postoperative patients, with the majority either undergoing abdominal or neurosurgery, compared 24 hours of postextubation support with either HFNC or BiPAP. After 24 hours, patients were switched to standard oxygen therapy. No differences in reintubation were noted between HFNC and BiPAP in the first 24 hours, but all-cause reintubation was a little lower with BiPAP (19.1%) versus HFNC (22.8%), as was respiratory related-reintubation (BiPAP 15.9% vs HFNC 16.9%), but none of these outcomes was statistically significant and this supports the conclusion of noninferiority of HFNC versus BiPAP for mixed causes of intubation. [34]

This experience led to a comparison of HFNC alone with HFNC and NIV postextubation in patients at high risk for extubation failure, defined as those older than 65 years and with underlying chronic cardiac or pulmonary disease. [35] These entities included those with left ventricular dysfunction defined by a left ventricular ejection fraction of less than or equal to 45% and prior cardiogenic pulmonary edema, ischemic heart disease, chronic atrial fibrillation, COPD, obesity-hypoventilation syndrome, or restrictive lung disease. Patients were also stratified on the presence or absence of hypercapnia (PaCO2 >45 mm Hg). Randomization to HFNC postextubation represented 48 hours of continuous HFNC oxygen, whereas the HFNC and NIV group were first treated with NIV for at least 4 hours postextubation and for 12 hours daily with HFNC during the period when off NIV in the 48 hours after extubation. If those in either group were stable after 48 hours, they were switched to conventional oxygen. The primary outcome was reintubation within 7 days of extubation ,and the investigators had preestablished reintubation criteria. Of 641 patients who were randomized, the NIV and HFNC group had lower reintubation rates at 48 hours, 72 hours, ICU discharge, and 7 days (11.8% vs 18.2%, P = .02) than the HFNC group. It should be noted that NIV was continued beyond the initial postextubation window of 48 hours in 25% and HFNC oxygen was continued in that group in 35% of patients. However, mortality was not different between the two groups, whether assessed during the ICU stay, hospital stay, or at 90 days. Of those in whom HFNC oxygen failed, 20 patients were then treated with NIV and half of those patient eventually needed reintubation. This report supports the combined use of NIV and HFNC oxygen as a successful postextubation strategy in those patients at high risk for respiratory failure.

In a meta-analysis of 18 trials involving 3881 patients, HFNC was associated with lower rates of intubation compared with conventional oxygen therapy in those with acute respiratory failure. However, no differences in intubation rates, ICU mortality, or ICU length of stay was found between HFNC and NIV in patients with acute respiratory failure. [36] This suggests that HFNC oxygen is not inferior to NIV in the management of these patients and can be an alternative method of support if there is concern for the use of NIV.


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