High-flow oxygen noninferior to noninvasive ventilation postextubation
Clinical Question: Is high-flow oxygen noninferior to noninvasive ventilation (NIV) in preventing postextubation respiratory failure and reintubation?
Background: Studies that suggest NIV usage following extubation reduces the risk of postextubation respiratory failure have led to an increase in use of this practice. Compared with NIV, high-flow, conditioned oxygen therapy has many advantages and fewer adverse effects, suggesting it might be a useful alternative.
Study design: Randomized clinical trial.
Setting: Three ICUs in Spain.
Synopsis: Investigators randomized 604 patients who were identified for planned extubation and at high risk of extubation failure to either NIV or high-flow oxygen therapy via nasal cannula for 24 hours following extubation. Per the noninferiority threshold, high-flow oxygen therapy was noninferior to NIV with respect to rates of reintubation (22.8% vs. 19.1%, respectively; one-sided 95% CI, –9.1% to ∞) and postextubation respiratory failure (26.9% vs. 39.8%, respectively; one-sided 95% CI, 6.6% to ∞).
Rates of most secondary outcomes, including infection, mortality, and hospital length of stay (LOS) were similar between the two groups. ICU LOS was significantly less in the high-flow oxygen group (3d vs. 4d; 95% CI, –6.8 to –0.8).
Additionally, every patient tolerated high-flow oxygen therapy, while 40% of patients in the NIV arm required withdrawal of therapy for at least 6 hours due to adverse effects (P less than .001).
Bottom line: High-flow oxygen immediately following extubation may be a useful alternative to NIV in preventing postextubation respiratory failure.
Citation: Hernández G, Vaquero C, González P, et al. Effect of postextubation high-flow nasal cannula vs conventional oxygen therapy on reintubation in low-risk patients: a randomized clinical trial. JAMA. 2016;315(13):1354-61.
Dr. Murphy is a clinical instructor at the University of Utah School of Medicine and an academic hospitalist at the University of Utah Hospital.
