Effect of postextubation noninvasive ventilation with active humidification vs high-flow nasal cannula on reintubation in patients at very high risk for extubation failure: a randomized trial

Abstract

Purpose High-flow nasal cannula (HFNC) oxygen therapy was noninferior to noninvasive ventilation (NIV) for preventing reintubation in a heterogeneous population at high-risk for extubation failure. However, outcomes might differ in certain subgroups of patients. Thus, we aimed to determine whether NIV with active humidification is superior to HFNC in preventing reintubation in patients with ≥ 4 risk factors (very high risk for extubation failure). Methods Randomized controlled trial in two intensive care units in Spain (June 2020‒June 2021). Patients ready for planned extubation with ≥ 4 of the following risk factors for reintubation were included: age > 65 years, Acute Physiology and Chronic Health Evaluation II score > 12 on extubation day, body mass index > 30, inadequate secretions management, difficult or prolonged weaning, ≥ 2 comorbidities, acute heart failure indicating mechanical ventilation, moderate-to-severe chronic obstructive pulmonary disease, airway patency problems, prolonged mechanical ventilation, or hypercapnia on finishing the spontaneous breathing trial. Patients were randomized to undergo NIV with active humidification or HFNC for 48 h after extubation. The primary outcome was reintubation rate within 7 days after extubation. Secondary outcomes included postextubation respiratory failure, respiratory infection, sepsis, multiorgan failure, length of stay, mortality, adverse events, and time to reintubation. Results Of 182 patients (mean age, 60 [standard deviation (SD), 15] years; 117 [64%] men), 92 received NIV and 90 HFNC. Reintubation was required in 21 (23.3%) patients receiving NIV vs 35 (38.8%) of those receiving HFNC (difference −15.5%; 95% confidence interval (CI) −28.3 to −1%). Hospital length of stay was lower in those patients treated with NIV (20 [12‒36.7] days vs 26.5 [15‒45] days, difference 6.5 [95%CI 0.5–21.1]). No additional differences in the other secondary outcomes were observed. Conclusions Among adult critically ill patients at very high-risk for extubation failure, NIV with active humidification was superior to HFNC for preventing reintubation. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-022-06919-3.

Effectiveness of high-flow nasal cannulae compared with noninvasive positive-pressure ventilation in preventing reintubation in patients receiving prolonged mechanical ventilation

“…Compared with the patients in the study by Hernandez et al, the patients in our study had a longer average duration of mechanical ventilation before extubation 21 . A previous report described that NIV can provide humidification through an active humidifier with a heated-wire respiratory circuit and is, therefore, superior to HFNC for preventing reintubation in patients at high risk of extubation failure 33 . Although we employed an active humidifier with a non–heated-wire respiratory circuit, the aforementioned result is consistent with the findings of our study.…”

The use of high-flow nasal oxygen

“…In high-risk patients (e.g., pre-existing respiratory or cardiac disease, or age > 65 years), alternating HFNO with noninvasive ventilation improves outcome compared to HFNO alone, especially in case of obesity [ 11 ]. In very high-risk patients, continuous noninvasive ventilation applied for 48 h seems to perform better than HFNO alone [ 12 ].…”

How to optimize extubation?

“…In patients with chronic obstructive pulmonary disease and heart failure, NIV is a therapeutic of choice in order to prevent extubation failure and was found to be superior to HFNO [12].…”