Patricia Kritek, MD reviewing Thille AW et al. JAMA 2019 Oct 2 Telias I and Ferguson ND. JAMA 2019 Oct 2
Noninvasive ventilation plus high-flow oxygen during breaks is a promising strategy.
Shortening the duration of mechanical ventilation has many benefits, including lowering risks for ventilator-associated pneumonia and delirium. Clinicians usually attempt extubation as soon as possible, with the knowledge that some extubated patients will require reintubation. In patients where risk for reintubation is particularly high, immediate support with noninvasive ventilation (NIV) or high-flow nasal cannula (HFNC) oxygen has been studied, but no clear “best practice” has been established.
Investigators in France randomized 641 patients at high risk for extubation failure (i.e., age, >65 or underlying cardiac or pulmonary disease) to 48 hours of either HFNC alone or NIV plus HFNC during breaks from NIV. Reintubation criteria were protocolized. Patients who received HFNC alone were significantly more likely to be reintubated within 7 days after extubation (18% vs. 12%). Similar results were found at 24 or 48 hours after extubation. The difference between groups was most pronounced in patients with partial pressure of carbon dioxide (PaCO2) >45 mm Hg at extubation.
Many clinicians routinely extubate patients with hypercarbic respiratory failure (most commonly due to underlying chronic obstructive pulmonary disease) to NIV. This study would broaden that approach to patients at high risk for reintubation (defined quite broadly in this study), regardless of gas exchange abnormalities. Use of HFNC during breaks from NIV is an interesting new strategy. Many patients don’t tolerate NIV well, but NIV with support during breaks with HFNC is worth trying.