Abstract
BackgroundIn intensive care units (ICUs), patients experiencing post-extubation respiratory failure have poor outcomes. The use of noninvasive ventilation (NIV) to treat post-extubation respiratory failure may increase the risk of death. This study aims at comparing mortality between patients treated with NIV alternating with high-flow nasal oxygen or high-flow nasal oxygen alone.MethodsPost-hoc analysis of a multicenter, randomized, controlled trial focusing on patients who experienced post-extubation respiratory failure within the 7 days following extubation. Patients were classified in the NIV group or the high-flow nasal oxygen group according to oxygenation strategy used after the onset of post-extubation respiratory failure. Patients reintubated within the first hour after extubation and those promptly reintubated without prior treatment were excluded. The primary outcome was mortality at day 28 after the onset of post-extubation respiratory failure.ResultsAmong 651 extubated patients, 158 (25%) experienced respiratory failure and 146 were included in the analysis. Mortality at day 28 was 18% (15/84) using NIV alternating with high-flow nasal oxygen and 29% (18/62) with high flow nasal oxygen alone (difference, − 11% [95% CI, − 25 to 2]; p = 0.12). Among the 46 patients with hypercapnia at the onset of respiratory failure, mortality at day 28 was 3% (1/33) with NIV and 31% (4/13) with high-flow nasal oxygen alone (difference, − 28% [95% CI, − 54 to − 6]; p = 0.006). The proportion of patients reintubated 48 h after the onset of post-extubation respiratory failure was 44% (37/84) with NIV and 52% (32/62) with high-flow nasal oxygen alone (p = 0.21).ConclusionsIn patients with post-extubation respiratory failure, NIV alternating with high-flow nasal oxygen might not increase the risk of death.Trial registration numberThe trial was registered at http://www.clinicaltrials.gov with the registration number NCT03121482 the 20th April 2017.
Highlights
In intensive care units (ICUs), patients experiencing post-extubation respiratory failure have poor outcomes
In patients with post-extubation respiratory failure, noninvasive ventilation (NIV) alternating with high-flow nasal oxygen might not increase the risk of death
We conducted a post-hoc analysis aimed at comparing the effects of NIV alternating with high-flow nasal oxygen vs. high-flow nasal oxygen alone on reintubation and mortality among patients experiencing post-extubation respiratory failure
Summary
In intensive care units (ICUs), patients experiencing post-extubation respiratory failure have poor outcomes. NIV used as rescue therapy to treat post-extubation respiratory failure could increase the risk of death by delaying reintubation [10]. NIV as rescue therapy may avoid reintubation in a number of cases, especially in hypercapnic patients with underlying chronic lung disease [7, 8, 12, 13], and recent large-scale clinical trials have shown that around 30 to 40% of patients with post-extubation respiratory failure are treated with NIV [1, 2]. Its beneficial effects have been reported in treatment of acute respiratory failure [17], high-flow nasal oxygen has never been studied for management of post-extubation respiratory failure, and the best oxygenation strategy in this setting remains unknown
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