Abstract
Reintubation after weaning from mechanical ventilation is relatively common and is associated with poor outcomes. Different methods to decrease the reintubation rate post extubation, including noninvasive ventilation, and more recently high-flow oxygen (HFO) therapy, have been proposed. In this study, we aimed to assess the safety of introducing HFO in the post-extubation care of intensive care unit (ICU) patients. We conducted a single-center cohort study of extubated adult patients hospitalized in a surgical ICU and previously mechanically ventilated for > 1 day. Our study consisted of two phases: Phase 1 (before the introduction of HFO from April 2015 to April 2016) and Phase P2 (after the introduction of HFO from April 2017 to April 2018). The primary endpoint was the reintubation rate within 48 hours of extubation. In total, 290 patients (median age 65 years [50-74]; 190 men [65.5%]) were included in the analysis (181 and 109 in Phases 1 and 2, respectively). The results of the post-extubation use of noninvasive methods (noninvasive ventilation and/or HFO) were not significantly different between the two phases (41 [22.7%] versus 29 [26.6%] patients; p = 0.480), however these methods were implemented earlier in Phase 2 (0 versus 4 hours; p = 0.009) and HFO was used significantly more often than noninvasive ventilation (24 [22.0%] versus 25 [13.8%] patients; p = 0.039). The need for reintubation within 48 hours post extubation was significantly lower in Phase 2 (4 [3.7%] versus 20 [11.0%] patients; p = 0.028) but was not significantly different at 7 days post extubation (10 [9.2%] versus 30 [16.6%] patients; p = 0.082). The earlier implementation of noninvasive methods and the increased use of HFO beginning in Phase 2 were safe and effective based on the reintubation rates within the first 48 hours post extubation and after 7 days.
Highlights
In intensive care units (ICUs), patients weaned from invasive mechanical ventilation are at risk of post-extubation respiratory failure and subsequent mechanical ventilation with tracheal reintubation [1,2]
The use of noninvasive ventilation (NIV) as supportive treatment to avoid tracheal reintubation is ineffective in 10–50% of patients with post-extubation ARF, two meta-analyses concluded that the early use of NIV could decrease reintubation rates [15,16]
high-flow conditioned oxygen therapy (HFO), a newly developed technology that delivers a high flow of high-concentration oxygen via nasal cannula, is able to generate mild continuous positive airway pressure [17], which reduces the work of breathing and clears out upper airway dead space [18]
Summary
In intensive care units (ICUs), patients weaned from invasive mechanical ventilation are at risk of post-extubation respiratory failure (acute respiratory failure [ARF]) and subsequent mechanical ventilation with tracheal reintubation [1,2]. Compared with conventional oxygen therapy, HFO therapy after extubation improves oxygenation and patient comfort and prevents post-extubation ARF and reintubation in general populations of critically ill patients [3,19]. Two prospective randomized controlled studies compared post-extubation NIV with HFO and found no difference in reintubation rates in critically ill medical and surgical patients [20,21] Analyses of these data, pooled in a meta-analysis, showed no significant difference in clinical outcomes between NIV and HFO [22]. The use of noninvasive methods has raised safety concerns [23] These therapies might increase the risk of poor outcomes due to the apparent improvements of patient comfort and oxygenation leading to delayed reintubation
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