Early extubation followed by immediate noninvasive ventilation vs. standard extubation in hypoxemic patients: a randomized clinical trial

Abstract

Purpose: Noninvasive ventilation (NIV) may facilitate withdrawal of invasive mechanical ventilation (i-MV) and shorten intensive care unit (ICU) length of stay (LOS) in hypercapnic patients, while data are lacking on hypoxemic patients. We aim to determine whether NIV after early extubation reduces the duration of i-MV and ICU LOS in patients recovering from hypoxemic acute respiratory failure. Methods: Highly selected non-hypercapnic hypoxemic patients were randomly assigned to receive NIV after early or standard extubation. Co-primary end points were duration of i-MV and ICU LOS. Secondary end points were treatment failure, severe events (hemorrhagic, septic, cardiac, renal or neurologic episodes, pneumothorax or pulmonary embolism), ventilator-associated pneumonia (VAP) or tracheobronchitis (VAT), tracheotomy, percent of patients receiving sedation after study enrollment, hospital LOS, and ICU and hospital mortality. Results: We enrolled 130 consecutive patients, 65 treatments and 65 controls. Duration of i-MV was shorter in the treatment group than for controls [4.0 (3.0-7.0) vs. 5.5 (4.0-9.0) days, respectively, p = 0.004], while ICU LOS was not significantly different [8.0 (6.0-12.0) vs. 9.0 (6.5-12.5) days, respectively (p = 0.259)]. Incidence of VAT or VAP (9% vs. 25%, p = 0.019), rate of patients requiring infusion of sedatives after enrollment (57% vs. 85%, p = 0.001), and hospital LOS, 20 (13-32) vs. 27(18-39) days (p = 0.043) were all significantly reduced in the treatment group compared with controls. There were no significant differences in ICU and hospital mortality or in the number of treatment failures, severe events, and tracheostomies. Conclusions: In highly selected hypoxemic patients, early extubation followed by immediate NIV application reduced the days spent on invasive ventilation without affecting ICU LOS.

Use of a helmet for oxygen therapy in critically ill patients: a systematic review and meta-analysis

“…12,16,19,22 Another study confirmed that early extubation followed by immediate NIV application with a full-face mask or helmet can reduce the number of days spent on invasive ventilation without affecting the intensive care unit length of stay in highly selected patients with hypoxaemia. 23 The results of this study show that use of a helmet does not have a significant benefit in terms of the oxygenation index and that compared with standard oxygen therapy or a mask, the helmet does not increase PaCO 2 . As when using the common mask, employing a helmet requires the patient to have effective independent breathing, clear respiratory secretions, and haemodynamic stability.…”

Prognostic Analysis of Elderly Patients with Multiple Organ Dysfunction Syndrome Undergoing Invasive Mechanical Ventilation

“…In addition, it was reported that MV duration is also a crucial factor influencing whether weaning can be successful [22]. Protracted MV duration is associated with respiratory muscle structural damage and muscle fiber remodeling, which leads to ventilator dependency.…”

Non-invasive Ventilation and High Flow Nasal Therapy in Acute Respiratory Failure: 2019 Novelties

“…Recent data confirmed that, in a general ICU population with difficult weaning, early extubation to NIV did not shorten time to liberation from any ventilation nor improved any outcome 81 . In contrast, more recently early extubation followed by immediate NIV in hypoxaemic patients resulted in shorter length of ventilation and hospital stay, and less incidence of ventilator-associated pneumonia, without changes in mortality, compared with standard extubation 82 .…”