High-Flow Nasal Oxygen With Ventilation Curbs Extubation Failure

By David Douglas

October 11, 2019

NEW YORK (Reuters Health) - In ICU patients at high risk of postextubation respiratory failure, noninvasive ventilation (NIV) along with high-flow nasal oxygen applied immediately after extubation reduces the rate of reintubation, a new randomized trial shows.

As many as 20% of patient ready to be separated from a ventilator experience extubation failure leading to reintubation, Dr. Arnaud Thille of Poitiers University Hospital, in France, and colleagues note in JAMA, online October 2.

Although international guidelines recommend the use of NIV to prevent postextubation respiratory failure, the team adds, in the absence of evidence from large clinical trials most patients in clinical practice are treated with standard oxygen.

To investigate further, the researchers studied 641 patients at 30 ICUs who were at high risk of extubation failure. All were older than 65 years or had underlying cardiac or respiratory disease. They were randomly assigned to high-flow nasal oxygen alone or high-flow nasal oxygen with NIV immediately after extubation.

After seven days, the reintubation rate was 11.8% in the NIV combination group, significantly lower than the 18.4% seen in the high-flow nasal oxygen alone patients.

The rate of postextubation respiratory failure was also significantly lower, at 21% versus 29%, as was the reintubation rate until ICU discharge (12% vs. 20%).

The median time to reintubation was not significantly different between groups. Although the ICU mortality rate was lower in the combination group (6%) it was not significantly different from that in patients receiving only nasal oxygen (9%).

Dr. Niall D. Ferguson of Toronto General Hospital, author of an accompanying editorial, told Reuters Health by email, "Despite being less convenient than using only high-flow nasal oxygen for many clinicians, this study inconveniently but probably correctly shows that the combination of NIV and high-flow nasal oxygen provides the best support for patients at higher risk of reintubation."

He adds in his editorial that "to get the most of this strategy, clinicians will have to use their clinical judgment to decide which patients within the high-risk nonhypercapnic group will benefit the most based on individual clinical and physiological characteristics."

Dr. Thille did not respond to requests for comments.

SOURCE: https://bit.ly/2AVSOxL

JAMA 2019.