Abstract
Background
Postextubation respiratory failure (PRF) frequently complicates weaning from mechanical ventilation and may increase morbidity/mortality. Noninvasive ventilation (NIV) alternating with high-flow nasal oxygen (HFNO) may prevent PRF.
Methods
Ventilated patients without chronic obstructive pulmonary disease (COPD) and at high-risk of PRF defined as a lung ultrasound score (LUS) ≥ 14 assessed during the spontaneous breathing trial, were included in a French-Chinese randomised controlled trial. PRF was defined by 2 among the following signs: SpO2 < 90%; Respiratory rate > 30 /min; hypercapnia; haemodynamic and/or neurological disturbances of respiratory origin. In the intervention group, prophylactic NIV alternating with HFNO was administered for 48 h following extubation. In the control group, conventional oxygen was used. Clinicians were informed on the LUS in the intervention group, those in the control group remained blind. The primary outcome was the incidence of PRF 48 h after extubation. Secondary outcomes were incidence of PRF and reintubation at day 7, number of ventilator-free days at day 28, length of ICU stay and mortality at day 28 and 90.
Results
Two hundred and forty patients were randomised and 227 analysed (intervention group = 128 and control group = 99). PRF at H48 was reduced in the intervention group compared to the control group: relative risk 0.52 (0.31 to 0.88), p = 0.01. The benefit persisted at day 7: relative risk 0.62 (0.44 to 0.96), p = 0.02. Weaning failure imposing reconnection to mechanical ventilation was not reduced. In patients who developed PRF and were treated by rescue NIV, reintubation was avoided in 44% of control patients and in 12% of intervention patients (p = 0.008). Other secondary outcomes were not different between groups. From a resource utilisation standpoint, prophylactic NIV alternating with HFNO was more demanding and costly than conventional oxygen with rescue NIV to achieve same clinical outcome.
Conclusions
Compared to conventional oxygenation, prophylactic NIV alternating with HFNO significantly reduced postextubation respiratory failure but failed to reduce reintubation rate and mortality in patients without COPD at high risk of extubation failure. Prophylactic NIV alternating with HFNO was as efficient as recue NIV to treat postextubation respiratory failure.
Key Points:
- Study Population: Included 227 mechanically ventilated patients (LUS ≥ 14), randomized to either prophylactic NIV+HFNO or conventional oxygen.
- Primary Outcome: Prophylactic NIV+HFNO reduced PRF incidence at 48 hours post extubation (19% vs. 28%, p = 0.01).
- Secondary Outcomes: PRF incidence at 7 days was lower in the intervention group (30% vs. 38%, p = 0.02), but no differences were observed in reintubation rates, ICU mortality, or length of ICU stay.
- Reintubation Rates: Similar reintubation rates were observed in both groups (22.2% vs. 24.2%, p = 0.72).
- Lung Ultrasound Utility: LUS ≥ 14 identified patients at high risk for PRF, enabling targeted intervention.
- Adverse Events: No significant differences in serious adverse events or respiratory discomfort between groups.
- Resource Utilization: Prophylactic NIV+HFNO was more resource-intensive and costly than conventional oxygen with rescue NIV for comparable clinical outcomes.
- Rescue NIV Effectiveness: Rescue NIV avoided reintubation in 44% of control patients with PRF, compared to 12% in the intervention group.
- Guideline Implications: Findings challenge prior guidelines suggesting superiority of prophylactic NIV+HFNO over rescue NIV in this population.
- Limitations: The study did not include COPD patients, limiting its applicability to this subgroup.
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