Post-extubation Respiratory Support Research Articles

Bi-level Positive Airway Pressure Versus Nasal CPAP for the Prevention of Extubation Failure in Infants After Cardiac Surgery.

Extubation early in the postoperative period is beneficial to the recovery and rehabilitation of patients. This study compared the postoperative extubation failure rates among infants who received postextubation respiratory support by either bi-level positive airway pressure (BPAP) or nasal CPAP following cardiac surgery. This was a single-center randomized controlled trial registered at the Chinese Clinical Trial Registry (number ChiCTR2000041453) and was conducted between January 2020 and March 2021. Ventilated infants who underwent cardiac surgery were randomized to either a BPAP or a nasal CPAP group for ventilatory support following extubation. The primary outcome measure was the extubation failure rate within 48 h. The analyses included 186 subjects. Treatment failure necessitating re-intubation was noted in 14 of the 93 infants (15%) in the BPAP group and in 11 of the 93 infants (12%) in the nasal CPAP group (P = .52). Moreover, there were no statistically significant differences between the 2 groups regarding the duration of noninvasive ventilation (P = .54), total enteral feeding time (P = .59), or complications (P = .85). We found that both the BPAP group and the nasal CPAP group showed significantly improved oxygenation and relief of respiratory distress after treatment. However, the PaCO2 level within 24 h was significantly lower in the BPAP group (P = .001) than in the CPAP group. Additionally, the PaO2 /FIO2 in the BPAP group was significantly higher than in the nasal CPAP group at 6 h, 12 h, and 24 h after treatment (P < .001). The introduction of BPAP for postextubation respiratory support was not inferior to nasal CPAP in infants after cardiac surgery. Moreover, BPAP was shown to be superior to nasal CPAP in improving oxygenation and carbon dioxide clearance.

Comparison of Two Noninvasive Ventilation Strategies (NHFOV Versus NIPPV) as Initial Postextubation Respiratory Support in High-Risk Infants After Congenital Heart Surgery

This study aimed to compare the effects of nasal high-frequency oscillatory ventilation (NHFOV) and noninvasive positive-pressure ventilation (NIPPV) as the initial postextubation therapies on preventing extubation failure (EF) in high-risk infants younger than three months after congenital heart surgery (CHS). This was a single-center, randomized, unblinded clinical trial. The study was performed in a teaching hospital. Between January 2020 and January 2021, a total of 150 infants underwent CHS in the authors' hospital. Infants younger than three months with a high risk for extubation failure who were ready for extubation were randomized to either an NHFOV therapy group or an NIPPV therapy group, and received the corresponding noninvasive mechanical ventilation to prevent EF. Primary outcomes were reintubation, long-term noninvasive ventilation (NIV) support (more than 72 hours), and the time in NIV therapy. The secondary outcomes were adverse events, including mild-moderate hypercapnia, severe hypercapnia, severe hypoxemia, treatment intolerance, signs of discomfort, unbearable dyspnea, inability to clear secretions, emesis, and aspiration. Of 92 infants, 45 received NHFOV therapy, and 47 received NIPPV therapy after extubation. There were no significant differences between the NHFOV and the NIPPV therapy groups in the incidences of reintubation, long-term NIV support, and total time under NIV therapy. No significant difference was found of the severe hypercapnia between the two groups, but NHFOV treatment significantly decreased the rate of mild-moderate hypercapnia (p < 0.05). Other outcomes were similar in the two groups. Among infants younger than three months after CHS who had undergone extubation, NIPPV therapy and NHFOV therapy were the equivalent NIV strategies for preventing extubation failure, and NHFOV therapy was more effective in avoiding mild-moderate hypercapnia.

Protocolized Postextubation Respiratory Support to Prevent Reintubation: A Randomized Clinical Trial.

Rationale: Respiratory support (noninvasive ventilation or high-flow nasal cannula) applied at the time of extubation has been reported to reduce reintubation rates, but concerns regarding effectiveness have limited uptake into practice.Objectives: To determine if providing postextubation respiratory support to all patients undergoing extubation in a medical ICU would decrease the incidence of reintubation.Methods: We conducted a pragmatic, two-armed, cluster-crossover trial of adults undergoing extubation from invasive mechanical ventilation between October 1, 2017, and March 31, 2019, in the medical ICU of an academic medical center. Patients were assigned to either protocolized postextubation respiratory support (a respiratory therapist-driven protocol in which patients with suspected hypercapnia received noninvasive ventilation and patients without suspected hypercapnia received high-flow nasal cannula) or usual care (postextubation management at the discretion of treating clinicians). The primary outcome was reintubation within 96 hours of extubation.Measurements and Main Results: A total of 751 patients were enrolled. Of the 359 patients assigned to protocolized support, 331 (92.2%) received postextubation respiratory support compared with 66 of 392 patients (16.8%) assigned to usual care, a difference driven by differential use of high-flow nasal cannula (74.7% vs. 2.8%). A total of 57 patients (15.9%) in the protocolized support group experienced reintubation compared with 52 patients (13.3%) in the usual care group (odds ratio, 1.23; 95% confidence interval, 0.82 to 1.84; P = 0.32).Conclusions: Among a broad population of critically ill adults undergoing extubation from invasive mechanical ventilation at an academic medical center, protocolized postextubation respiratory support, primarily characterized by an increase in the use of high-flow nasal cannula, did not prevent reintubation compared with usual care.Clinical trial registered with www.clinicaltrials.gov (NCT0328831).

Extubation to High-Flow Nasal Cannula in Infants Following Cardiac Surgery: A Retrospective Cohort Study.

High-flow nasal cannula (HFNC) therapy is commonly used in the pediatric intensive care unit (PICU) for postextubation respiratory support. This hypothesis-generating retrospective cohort study aimed to compare postextubation PICU length of stay in infants extubated to HFNC and low flow oxygen (LF) in PICU following cardiac surgery. Of 136 infants (newborn to 1 year) who were intubated and mechanically ventilated in PICU following cardiac surgery, 72 (53%) were extubated to HFNC and 64 (47%) to LF. Compared with patients extubated to LF, those extubated to HFNC had significantly longer durations of cardiopulmonary bypass (152 vs. 109 minutes; p = 0.002), aortic cross-clamp (90 vs. 63 minutes; p = 0.003), and invasive mechanical ventilation (3.2 vs. 1.6 days; p < 0.001), although demographic and preoperative clinical variables were similar. No significant difference was observed in postextubation PICU length of stay between HFNC and LF groups in unadjusted analysis (3.3 vs. 2.6 days, respectively; p = 0.19) and after controlling for potential confounding variables (F [1,125] = 0.17, p = 0.68, R 2 = 0.16). Escalation of therapy was similar between HFNC and LF groups (8.3 vs. 14.1%; p = 0.41). HFNC was effective as rescue therapy for six patients in the LF group requiring escalation of therapy. Need for reintubation was similar between HFNC and LF groups (8.3 vs. 4.7%; p = 0.5). Although extubation to HFNC was associated with a trend toward longer postextubation PICU length of stay and was successfully used as rescue therapy for several infants extubated to LF, our results must be interpreted with caution given the limitations of our study.

Comparison between continuous positive airway pressure and T piece as spontaneous breathing trial at a tertiary care pediatric intensive care unit

Background: A spontaneous breathing trial (SBT) is often used to decide about extubation readiness in mechanically ventilated patients. Studies done to identify the best method of SBT have shown variable results. As there was no published data comparing continuous positive airway pressure (CPAP) and T piece, this study was conducted to compare CPAP and T piece as method of SBT for postextubation outcomes. Subjects and Methods: This study was a pilot randomized controlled trial conducted at a tertiary care pediatric intensive care unit (PICU) from November 2018 to October 2019. Criteria for starting SBT and to identify trial as failure were predefined. Sixty patients were included in the study and randomly assigned to CPAP and T-piece group, of 30 each. Demographic data, diagnosis, duration of mechanical ventilation (MV), endotracheal tube size, need of inotropes, vasopressors, and sedation were all recorded. The primary outcome of the study was extubation failure within 48 h. The secondary outcomes studied were mortality, need of respiratory support, duration of oxygen requirement, and length of PICU (LOPICU) stay after extubation. Results: Age, gender, indication of intubation, duration of MV, and number of SBT attempts were similar in both the groups. There was no statistically significant difference in extubation failure within 48 h between the two groups. Four patients were reintubated in both the groups and two patients died in T piece group and one patient in CPAP group. Postextubation respiratory support, duration of oxygen therapy, LOPICU stay, and mortality were not significant different between the two groups. Conclusion: There was no significant difference in extubation outcomes when CPAP and T piece were used as methods of SBT.

Nasal HFOV versus nasal IPPV as a post-extubation respiratory support in preterm infants-a randomised controlled trial.

Early and successful extubation prevents several morbidities in preterm newborns. Several secondary non-invasive respiratory modalities exist but with their merits and demerits. Given the benefits of nasal high-frequency oscillatory ventilation (nHFOV), we tried to examine whether nHFOV could reduce reintubation rates compared to nasal intermittent positive pressure ventilation (NIPPV) during the post-extubation phase in preterm infants. Stratified randomisation based on gestational age was done for 86 mechanically ventilated preterm infants between 26 and 36+6 weeks of gestation within 2 weeks of age to receive either nHFOV or NIPPV post-extubation. The main objective was to compare extubation failure within 72 h following extubation and secondarily feed intolerance, intraventricular haemorrhage (IVH) (> grade 3), composite bronchopulmonary dysplasia (BPD)/mortality, composite duration of oxygen supplementation/ventilation support and SpO2/FiO2 ratio. No statistical difference was noted for primary outcome (RR 0.8, 95% CI: 0.23 to 2.78; p = 1.00) and secondary outcomes. However, nHFOV appeared possibly better in respect to feed tolerance rates and pCO2 washout.Conclusion: Extubation failure within 72 h in infants less than 37 weeks of gestation did not differ between the two groups. However, nHFOV seems promising in reducing enteral feeding issues and pCO2 elimination. Larger multicentre studies are required for exploring benefits of nHFOV.Trial registration: www.ctri.nic.in id CTRI/2019/07/020055, registration date July 5, 2019 What is Known:• NIPPV is superior to nCPAP as a secondary mode of respiratory support.• Synchronisation is preferred for optimum ventilation.What is New:• nHFOV, a novel non-invasive respiratory modality without need for synchronisation, appears promising as a secondary mode subject to further trials.• It seems promising in reducing enteral feeding issues and pCO2 elimination.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00431-021-04084-1.

Post-extubation oxygenation strategies in acute respiratory failure: a systematic review and network meta-analysis

BackgroundHigh-flow nasal cannula oxygenation (HFNC) and noninvasive positive-pressure ventilation (NPPV) possibly decrease tracheal reintubation rates better than conventional oxygen therapy (COT); however, few large-scale studies have compared HFNC and NPPV. We conducted a network meta-analysis (NMA) to compare the effectiveness of three post-extubation respiratory support devices (HFNC, NPPV, and COT) in reducing the mortality and reintubation risk.MethodsThe Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and Ichushi databases were searched. COT, NPPV, and HFNC use were assessed in patients who were aged ≥ 16 years, underwent invasive mechanical ventilation for > 12 h for acute respiratory failure, and were scheduled for extubation after spontaneous breathing trials. The GRADE Working Group Approach was performed using a frequentist-based approach with multivariate random-effect meta-analysis. Short-term mortality and reintubation and post-extubation respiratory failure rates were compared.ResultsAfter evaluating 4631 records, 15 studies and 2600 patients were included. The main cause of acute hypoxic respiratory failure was pneumonia. Although NPPV/HFNC use did not significantly lower the mortality risk (relative risk [95% confidence interval] 0.75 [0.53–1.06] and 0.92 [0.67–1.27]; low and moderate certainty, respectively), HFNC use significantly lowered the reintubation risk (0.54 [0.32–0.89]; high certainty) compared to COT use. The associations of mortality with NPPV and HFNC use with respect to either outcome did not differ significantly (short-term mortality and reintubation, relative risk [95% confidence interval] 0.81 [0.61–1.08] and 1.02 [0.53–1.97]; moderate and very low certainty, respectively).ConclusionNPPV or HFNC use may not reduce the risk of short-term mortality; however, they may reduce the risk of endotracheal reintubation.Trial registration number and date of registrationPROSPERO (registration number: CRD42020139112, 01/21/2020).

Randomised controlled trial of high-flow nasal cannula in preterm infants after extubation.

HFNC therapy is increasingly used as ‘non-invasive’ respiratory support for preterm infants. A 2016 Cochrane Review found that HFNC had similar efficacy to NCPAP for preterm infants following extubation,1 but that further studies were needed, particularly in extremely preterm infants born <28 weeks' gestation, who are at highest risk of extubation failure. The trial by Uchiyama et al is the largest randomised trial of HFNC as post-extubation support in preterm infants, and one of only a few to enrol extremely preterm infants (168 infants enrolled; 76 HFNC, 92 NCPAP/NIPPV). This multicentre non-inferiority trial found NCPAP/NIPPV was superior to HFNC (and HFNC did not satisfy non-inferiority criteria) for the primary outcome of treatment failure within 7 days. Reintubation rates were similar; more than 80% of infants who met HFNC treatment failure criteria avoided reintubation due to crossover to NCPAP/NIPPV. Like previous similar trials2-4 the intervention was not blinded, although objective treatment failure criteria were used. In the NCPAP/NIPPV group, 149 infants received NCPAP and 47 received NIPPV at extubation. In both groups, the escalation of respiratory support was at clinician discretion. As the control group could receive either NCPAP or NIPPV, the definition of ‘treatment failure’ is blurred: some infants received NIPPV before ‘treatment failure’ and others did not. It is not reported whether NIPPV inflations were synchronised with the infant's breathing or not, which may be important.5 A non-inferiority trial design is reasonable given the existing evidence, although the sample size calculation assumed a HFNC treatment failure rate 9% higher than that of NCPAP/NIPPV, and the chosen non-inferiority margin was rather large. There is an imbalance in the allocation of infants to HFNC (47%) and NCPAP/NIPPV (53%). A total of 378 infants were ultimately recruited to the study (38 more than required, even with inflation for anticipated dropouts); however this represents only 33% of eligible infants, which has implications for generalisability of the results. The use of respiratory stimulants prior to extubation is not reported. The trial was prospectively registered; however, there are inconsistencies between the registration and the published trial in the stated sample size, comparator and primary outcome. The starting HFNC gas flow was >2 L/min, lower than some previous studies,3, 4 and it is unclear whether infants received the maximal permitted gas flow of 8 L/min prior to treatment failure being determined. As increasing gas flow is associated with increased delivered pressure,6 this may have contributed to decreased efficacy in the HFNC group. Extubation failure in preterm infants is an important concern for neonatal clinicians, and the optimal mode of post-extubation respiratory support remains uncertain. The results of the trial by Uchiyama et al may tip the balance in favour of NCPAP/NIPPV as initial post-extubation support; however, consistent with previous evidence, reintubation rates are similar when HFNC is used with the ‘backup’ of NCPAP/NIPPV. For the most immature infants at highest risk of extubation failure, it seems prudent to avoid using HFNC as initial post-extubation support. The authors have no conflicts of interest to declare. https://ebneo.org/HFNC-after-extubation

Non-invasive high-frequency oscillatory ventilation in preterm infants after extubation: a randomized, controlled trial.

ObjectiveTo investigate the effectiveness and safety of non-invasive high-frequency oscillatory ventilation (NHFOV) in post-extubation preterm infants.MethodsThis was a randomized, controlled trial. A total of 149 preterm infants aged between 25 to 34 weeks’ gestational age with a birth weight of <1500 g who required invasive mechanical ventilation on admission were included. After extubation, they were randomized to the NHFOV group (n = 47), nasal intermittent positive pressure ventilation (NIPPV) group (n = 51), or nasal continuous positive airway pressure (NCPAP) group (n = 51). We compared the effectiveness and safety among these three groups.ResultsA total of 139 preterm infants finally completed the study. The reintubation rate was significantly lower in the NHFOV group than in the other groups. The duration of non-invasive ventilation and the length of hospital stay in the NHFOV and NIPPV groups were significantly shorter than those in the NCPAP group. The incidence of bronchopulmonary dysplasia in the NHFOV and NIPPV groups was significantly lower than that in the NCPAP group. The NHFOV group had significantly less nasal injury than the NCPAP group.ConclusionAs post-extubation respiratory support in preterm infants, NHFOV has a lower reintubation rate compared with NCPAP and NIPPV, without increasing the rate of complications.

Heated Humidified High-Flow Nasal Cannula vs. Nasal Continuous Positive Airway Pressure for Post-extubation Respiratory Support in Preterm Infants: A Randomized Controlled Trial.

The objective of this study was to compare the efficacy and safety of heated humidified high-flow nasal cannula (HHHFNC) and nasal continuous positive airway pressure (nCPAP) for prevention of extubation failure in preterm infants. Preterm infants (gestation ≥28 weeks) were randomized to HHHFNC or nCPAP after extubation. Primary outcome was extubation failure within 72 h of extubation. A total of 128 preterm infants were randomized to receive either HHHFNC (n = 63) or nCPAP (n = 65) after extubation. The primary outcome of extubation failure within 72 h after extubation was not different between the two groups (HHHFNC, 22.2% vs. nCPAP, 18.5%, risk difference of 3.7% and 95% CI -10.3 to 17.6, p = 0.604). The incidence of nasal trauma was significantly lower in the HHHFNC group than in the nCPAP group 6.3% vs. 21.5%, p = 0.020. In our study, HHHFNC was as effective as nCPAP for prevention of extubation failure in preterm infants. Also, HHHFNC was associated with significantly less nasal trauma compared with nCPAP.

Efficacy of high-flow nasal cannula versus nasal continuous positive airway pressure in the treatment of respiratory distress syndrome in neonates: a Meta analysis

Objective To systematically evaluate the efficacy and safety of high-flow nasal cannula (HFNC) therapy versus nasal continuous positive airway pressure (nCPAP) in the treatment of respiratory distress syndrome (RDS) in neonates. Methods PubMed, Embase, Cochrane Library, Web of Science, China Biology Medicine disc, Wanfang Database, CNKI, and Weipu Database were searched for the randomized controlled trials (RCTs) of HFNC versus nCPAP in the treatment of neonatal RDS published up to April 1, 2020. RevMan5.3 software was used to perform a Meta analysis of the eligible RCTs. Results A total of 12 RCTs were included, with 2 861 neonates in total, among whom 2 698 neonates (94.30%) had a gestational age of ≥28 weeks and 163 (5.70%) had a gestational age of 0.05). For primary respiratory support and post-extubation respiratory support, the HFNC group had a significantly lower incidence rate of nasal injury than the nCPAP group (P 0.05). Conclusions Based on the current clinical evidence, HFNC has a higher failure rate than nCPAP when used as primary respiratory support for neonates with RDS, and therefore it is not recommended to use HFNC as the primary respiratory support for neonates with RDS. In RDS neonates with a gestational age of ≥28 weeks, HFNC can be used as post-extubation respiratory support in the weaning phase.

Efficacy of noninvasive respiratory support modes as postextubation respiratory support in preterm neonates: A systematic review and network meta-analysis.

Multiple noninvasive respiratory support (NRS) modalities are used for postextubation support in preterm neonates. Seven NRS modalities were compared-constant flow continuous positive airway pressure (CPAP) (CF-CPAP) (bubble CPAP; ventilator CPAP), variable flow CPAP (VF-CPAP), high flow nasal cannula (HFNC), synchronized noninvasive positive pressure ventilation (S-NIPPV), nonsynchronized NIPPV (NS-NIPPV), bilevel CPAP (BiPAP), noninvasive high-frequency oscillation ventilation (nHFOV). Systematic review and network meta-analysis (NMA) using the Bayesian random-effects approach. MEDLINE, EMBASE, CENTRAL, WHO-ICTRP were searched. Requirement of invasive mechanical ventilation within 7 days of extubation. A total of 33 studies with 4080 preterm neonates were included. S-NIPPV, NS-NIPPV, nHFOV, and VF-CPAP were more efficacious in preventing reintubation than CF-CPAP (risk ratio [RR] [95% credible intervals {CrI}]: 0.22 [0.12, 0.35]; 0.44 [0.27, 0.67]; 0.42 [0.18, 0.81]; 0.73 [0.52, 0.99]). Surface under the cumulative ranking curve (SUCRA) value ranked S-NIPPV to be the best postextubation intervention (SUCRA: 0.98). S-NIPPV was more effective than NS-NIPPV, BiPAP, VF-CPAP, and HFNC (RR [95% CrI]: 0.52 [0.24, 0.97]; 0.32 [0.14, 0.64]; 0.30 [0.16, 0.50]; 0.24 [0.12, 0.41]). NS-NIPPV resulted in lesser reintubation compared to VF-CPAP and HFNC (RR [95% CrI]: 0.61 [0.36, 0.97]; 0.49 [0.27, 0.80]). BiPAP, VF-CPAP, and HFNC had comparable efficacies. The overall quality of evidence was very low to moderate. Results of this NMA indicate that S-NIPPV might be the most effective and CF-CPAP the least effective NRS modality for preventing extubation failure.

Effect of high-flow nasal cannula versus conventional oxygen therapy and non-invasive ventilation for preventing reintubation: a Bayesian network meta-analysis and systematic review.

BackgroundAdequate respiratory support can improve clinical outcomes in patients who are ready for weaning from a ventilator. We aimed to investigate the efficacy of respiratory methods in adults undergoing planned extubation using a Bayesian network meta-analysis.MethodsWe searched PubMed, Embase, and ClinicalTrials.gov for unpublished and ongoing trials up to November 2019 for randomized controlled trials (RCTs) published in English that compared conventional oxygen therapy (COT), a high-flow nasal cannula (HFNC), and noninvasive ventilation (NIV) for post-extubation respiratory support. Screening of citations, study selection, data extraction, and assessment of risk were performed independently by two authors. The primary outcome was the reintubation rate.ResultsTwenty-two studies (4,218 patients) were included in our meta-analysis. Extubated patients supported with NIV had a significantly lower incidence of reintubation than those supported with COT [odds ratio (OR): 0.63, 95% confidence interval (CI): 0.42, 0.89]. However, there was no significant difference in the reintubation rate between the HFNC and NIV, and HFNC and COT groups (OR: 1.05, 95% CI: 0.60, 1.81; OR: 0.60, 95% CI: 0.33, 1.02, respectively). HFNC and NIV reduced the incidence of hospital-acquired pneumonia (HAP) (OR: 0.50, 95% CI: 0.25, 0.93; OR: 0.55, 95% CI: 0.27, 0.87, respectively) and post-extubation acute respiratory failure (ARF) (OR: 0.35, 95% CI: 0.14, 0.89; OR: 0.31, 95% CI: 0.14, 0.63, respectively) compared with COT. There was no significant difference in a decreased incidence of HAP (OR: 1.1, 95% CI: 0.56, 1.8) or post-extubation ARF (OR: 0.87, 95% CI: 0.33, 2.1) between NIV and HFNC. There were also no significant differences in improvements in other clinical outcomes, including intensive care unit (ICU) and hospital mortality and the length of stay (LOS) between NIV and HFNC.ConclusionsNIV reduces the reintubation rate in adult patients undergoing planned extubation compared with COT and HFNC.

Dead Space to Tidal Volume Ratio Is Associated With Higher Postextubation Support in Children.

Extubation failure is associated with increased duration of mechanical ventilation, length of hospital stay, and mortality. An elevated dead-space-to-tidal-volume ratio (VD/VT) has been proposed as a predictor of successful extubation in children. We hypothesized that a higher VD/VT value would be associated with extubation failure and higher postextubation respiratory support. This was a prospective, observational, cohort study. All subjects were < 18 y old and were extubated in the pediatric multidisciplinary ICU or the cardiac ICU at an academic medical center from June 2016 through March 2017. Using arterial blood gas analysis and mainstream volumetric capnography, daily VD/VT measurements were obtained on intubated subjects using an automated algorithm. Respiratory support upon extubation was based on the clinical team's judgment and defined as low (ie, room air or nasal cannula) or high (ie, high-flow nasal cannula, CPAP, or bi-level positive airway pressure). Subjects were monitored for 48 h after extubation for escalation in respiratory support and need for re-intubation. Of 189 subjects included in the analysis, 166 were successfully extubated and 23 (12%) required re-intubation. There was no significant difference in final VD/VT between those who extubated successfully and those who failed extubation, with a median VD/VT of 0.28 (interquartile range [IQR] 0.20-0.37) vs 0.29 (IQR 0.21-0.33), respectively (P = .87). Those who received a high level of support upon extubation had a higher VD/VT than those who received a low level of support, with a median of 0.32 (IQR 0.23-0.39) vs 0.25 (IQR 0.16-0.30), respectively (P < .001). This association remained significant when controlling for age, duration of intubation, and cyanotic congenital heart disease (odds ratio 1.63, 95% CI 1.18-2.24). There was no significant relationship between VD/VT and extubation success, although VD/VT was associated with the level of respiratory support provided following extubation. Further studies should investigate whether the use of VD/VT can help reduce extubation failure rates with varying levels of postextubation respiratory support.

Protocolized Post-Extubation Respiratory Support to prevent reintubation: protocol and statistical analysis plan for a clinical trial

IntroductionFollowing extubation from invasive mechanical ventilation, nearly one in seven critically ill adults requires reintubation. Reintubation is independently associated with increased mortality. Postextubation respiratory support (non-invasive ventilation or high-flow nasal...

High-flow nasal cannula versus nasal continuous positive airway pressure for respiratory support in preterm infants: a meta-analysis of randomized controlled trials

Background: As a noninvasive respiratory support mode, high-flow nasal cannula (HFNC) is widely used in preterm infants at neonatal care units. HFNC is often used as an alternative to nasal continuous positive airway pressure (NCPAP) for initial or post-extubation respiratory support. The purpose of this meta-analysis is to evaluate and compare the efficacy and safety of HFNC and NCPAP for respiratory support in preterm infants.Methods: We searched PubMed, Web of Science, Embase, Cochrane Library, Clinicaltrials.gov, Controlled-trials.com, Google Scholar, VIP, and Wang Fang for articles from their inception to December 2018. All published randomized controlled trials (RCTs) evaluating and comparing the effects of HFNC and NCPAP therapy for primary respiratory support in newborns were included. All meta-analyses were performed using Review Manager 5.3.Results: In total, 21 RCTs involving 2886 preterm infants were included. The results of the meta-analysis revealed the following: (1) for primary respiratory support, the rates of treatment failure at trial entry were similar between HFNC and CPAP (relative risk 1.03, 95% confidence interval 0.79–1.33), and HFNC had reduced nasal trauma (p < .00001); and (2) for respiratory support after extubation, CPAP was associated with a lower likelihood of treatment failure than HFNC (relative risk 1.23, 95% confidence interval 1.01–1.50). The incidences of nasal trauma and pneumothorax in the HFNC group were significantly lower than that in the CPAP group (p < .0001 and p = .03). Serious adverse events did not significantly differ.Conclusions: HFNC had effects similar to those of CPAP regarding the failure of initial respiratory support in premature infants and was associated with reduced nasal trauma compared to CPAP. Following extubation, CPAP had fewer treatment failures than HFNC, but CPAP had a significantly increased rate of nasal trauma and pneumothorax. Further studies are needed to clarify the potential benefits of HFNC as primary respiratory support in extremely low birth weight or extremely preterm infants.

The clinical practice of high-flow nasal cannula oxygen therapy in adults: A Japanese cross-sectional multicenter survey.

High-flow nasal cannula oxygen therapy (HFNC) is widely used mainly in the acute care setting, but limited data are available on real-world practice in adults. The objective of this study was to describe HFNC practices in Japanese adults. A retrospective cross-sectional multicenter survey of adult patients receiving HFNC from January through March 2015 was conducted in 33 participating hospitals in Japan. We obtained information on 321 patients (median age, 76; 218 men, 103 women; median estimated PaO2/FIO2, 178 mm Hg) from 22 hospitals. Do-not-intubate status was determined in 37.4% of patients. Prior to HFNC, 57.9% of patients received conventional oxygen therapy; 25.9%, noninvasive ventilation; and 15.0%, invasive mechanical ventilation. The common indications for HFNC were acute hypoxemic respiratory failure (ARF) (65.4%), postoperative respiratory support (15.9%), and post-extubation respiratory support (11.2%). The underlying etiology of ARF included interstitial lung disease, pneumonia, and cardiogenic pulmonary edema. HFNC was administered mostly in intensive care units or intermittent care units (60.7%) and general wards (36.1%). Median duration of HFNC was 4 days; median total flow rate, 40 L/min; and median FIO2, 50%. HFNC significantly improved PaO2, PaCO2, SpO2 and respiratory rate from baseline. Two-thirds of patients finally survived to be discharged or transferred. We documented patient demographics, clinical indications, and settings of HFNC use in the real world. We also demonstrated positive effects of HFNC on respiratory parameters. Further studies are urgently needed regarding the efficacy and safety of HFNC in populations outside of previous clinical trials.

The mechanism of heated humidified high flow nasal cannula oxygen therapy and its application in pediatrics

Heated humidified high flow nasal cannula oxygen therapy (HFNC) has the characteristics of improving the work of breathing, creating the effect of positive end-expiratory pressure, being setted up easily, well tolerated by patients and high safety.At present, it has been widely used in neonatal respiratory support, but lack of its extensive use and research in infants and children.HFNC is suitable for use in infants with viral bronchiolitis, pneumonia, asthma, ARDS, and postextubation respiratory support from the aspect of the mechanism of action of HFNC and the pediatric physiology.HFNC should be the preferred mode of conventional oxygen therapy in pediatrics. Key words: Pediatrics; Heated humidified; High flow; Oxygen therapy,

Pediatric extubation readiness tests should not use pressure support.

Pressure support is often used for extubation readiness testing, to overcome perceived imposed work of breathing from endotracheal tubes. We sought to determine whether effort of breathing on continuous positive airway pressure (CPAP) of 5cmH2O is higher than post-extubation effort, and if this is confounded by endotracheal tube size or post-extubation noninvasive respiratory support. Prospective trial in intubated children. Using esophageal manometry we compared effort of breathing with pressure rate product under four conditions: pressure support 10/5cmH2O, CPAP 5cmH2O (CPAP), and spontaneous breathing 5 and 60min post-extubation. Subgroup analysis excluded post-extubation upper airway obstruction (UAO) and stratified by endotracheal tube size and post-extubation noninvasive respiratory support. We included 409 children. Pressure rate product on pressure support [100 (IQR 60, 175)] was lower than CPAP [200 (120, 300)], which was lower than 5min [300 (150, 500)] and 60min [255 (175, 400)]post-extubation (all p<0.01). Excluding 107 patients with post-extubation UAO (where pressure rate product after extubation is expected to be higher), pressure support still underestimated post-extubation effort by 126-147%, and CPAP underestimated post-extubation effort by 17-25%. For all endotracheal tube subgroups, ≤3.5mmID (n=152), 4-4.5mmID (n=102), and ≥5.0mmID (n=48), pressure rate product on pressure support was lower than CPAP and post-extubation (all p<0.0001), while CPAP pressure rate product was not different from post-extubation (all p<0.05). These findings were similar for patients extubated to noninvasive respiratory support, where pressure rate product on pressure support before extubation was significantly lower than pressure rate product post-extubation on noninvasive respiratory support (p<0.0001, n=81). Regardless of endotracheal tube size, pressure support during extubation readiness tests significantly underestimates post-extubation effort of breathing.

Use of high-flow nasal cannula in neonates: Nationwide survey in Japan.

High-flow nasal cannula is a new modality of respiratory support and is increasing in popularity despite the lack of supporting evidence. We investigated the prevalence of its use in tertiary neonatal units in Japan. A paper-based survey was conducted. The response rate was 83%. High-flow nasal cannula was used in 46/80 units (58%), of which 96% used the high-flow nasal cannula without guidelines. It was used for several indications, including weaning off nasal continuous positive airway pressure and post-extubation respiratory support. The main perceived benefits of the cannula included better access to the neonate and reduced risk of nasal trauma. This survey found that high-flow nasal cannula is used without clear criteria and that clinical practice varies across neonatal units in Japan. Its use in neonates needs to be urgently evaluated.