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Original Investigation
Caring for the Critically Ill Patient
October 2, 2019

Effect of Postextubation High-Flow Nasal Oxygen With Noninvasive Ventilation vs High-Flow Nasal Oxygen Alone on Reintubation Among Patients at High Risk of Extubation Failure: A Randomized Clinical Trial

Author Affiliations
  • 1Centre Hospitalier Universitaire de Poitiers, Médecine Intensive Réanimation, Poitiers, France
  • 2INSERM Centre d’Investigation Clinique 1402 ALIVE, Université de Poitiers, Poitiers, France
  • 3Groupe Hospitalier Régional d’Orléans, Médecine Intensive Réanimation, Orléans, France
  • 4Centre Hospitalier Universitaire de Rennes, Hôpital Ponchaillou, Service des Maladies Infectieuses et Réanimation Médicale, Rennes, France
  • 5Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S), AP-HP, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, Paris, France
  • 6Hôpital Bichat–Claude Bernard, Médecine Intensive Réanimation, AP-HP, Université Paris Diderot, Paris, France
  • 7Centre Hospitalier Universitaire d’Angers, Département de Médecine Intensive Réanimation, Université d’Angers, Angers, France
  • 8Centre Hospitalier Universitaire de Rouen, Hôpital Charles Nicolle, Département de Réanimation Médicale, Normandie Université, UNIROUEN, EA3830-GRHV, Institute for Research and Innovation in Biomedicine (IRIB), Rouen, France
  • 9Centre Hospitalier Universitaire Félix Guyon, Service de Réanimation Polyvalente, Saint Denis de la Réunion, France
  • 10Centre Hospitalier Universitaire de Clermont-Ferrand, Hôpital Gabriel Montpied, Service de Réanimation Médicale, Clermont-Ferrand, France
  • 11Centre Hospitalier de La Rochelle, Service de Réanimation, La Rochelle, France
  • 12Centre Hospitalier Universitaire de Lille, Centre de Réanimation, Université de Lille, Lille, France
  • 13Hôpital Saint-Joseph Saint-Luc, Réanimation Polyvalente, Lyon, France
  • 14Centre Hospitalier Universitaire de Nantes, Médecine Intensive Réanimation, Nantes, France
  • 15Hôpital Louis Mourier, Réanimation Médico-Chirurgicale, AP-HP, INSERM, Université Paris Diderot, UMR IAME 1137, Sorbonne Paris Cité, Colombes, France
  • 16Hôpitaux universitaires Henri Mondor, Service de Réanimation Médicale DHU A-TVB, AP-HP, Créteil, France
  • 17Groupe Hospitalier Régional Mulhouse Sud Alsace, site Emile Muller, Service de Réanimation Médicale, Mulhouse, France
  • 18Centre Hospitalier Départemental de Vendée, Service de Médecine Intensive Réanimation, La Roche Sur Yon, France
  • 19Centre Hospitalier Régional Universitaire de Tours, Médecine Intensive Réanimation, CIC 1415, Réseau CRICS-Trigger SEP, Centre d'étude des pathologies respiratoires, INSERM U1100, Université de Tours, Tours, France
  • 20Centre Hospitalier de Pau, Service de Réanimation, Pau, France
  • 21Centre Hospitalier Universitaire La Timone 2, Médecine Intensive Réanimation, Réanimation des Urgences, Aix-Marseille Université, Marseille, France
  • 22Centre Hospitalier Henri Mondor d’Aurillac, Service de Réanimation, Aurillac, France
  • 23Centre Hospitalier Universitaire de Brest, Médecine Intensive Réanimation, Brest, France
  • 24Centre Hospitalier Universitaire Grenoble Alpes, Médecine Intensive Réanimation, INSERM, Université Grenoble-Alpes, U1042, HP2, Grenoble, France
  • 25Centre Hospitalier Universitaire de Nice, Médecine Intensive Réanimation, Archet 1, Université Cote d’Azur, Nice, France
  • 26Centre Hospitalier de Versailles, Service de Réanimation Médico-Chirurgicale, Le Chesnay, France
  • 27Centre Hospitalier Universitaire de Nice, Réanimation Médico-Chirurgicale Archet 2, INSERM U 1065, Nice, France
  • 28Centre Hospitalier Universitaire de Poitiers, Réanimation Chirurgicale, Poitiers, France
  • 29Hôpital Tenon, Réanimation et USC médico-chirurgicale, CARMAS, AP-HP, Faculté de médecine Sorbonne Université, Collegium Galilée, Paris, France
  • 30Centre Hospitalier Emile Roux, Service de Réanimation, Le Puy en Velay, France
  • 31Hôpital Lariboisière, Réanimation Médicale et Toxicologique, AP-HP, INSERM UMR-S 942, Paris, France
JAMA. 2019;322(15):1465-1475. doi:10.1001/jama.2019.14901
Key Points

Question  Among mechanically ventilated patients at high risk of extubation failure, does the use of high-flow nasal oxygen with noninvasive ventilation after extubation reduce the risk of reintubation compared with high-flow nasal oxygen alone?

Findings  In this randomized clinical trial that included 641 patients, high-flow nasal oxygen with noninvasive ventilation, compared with high-flow nasal oxygen alone, significantly decreased the rate of reintubation within the first 7 days after extubation (11.8% vs 18.2%).

Meaning  In patients at high risk of extubation failure, the use of high-flow nasal oxygen with noninvasive ventilation after extubation significantly decreased the risk of reintubation compared with high-flow nasal oxygen alone.

Abstract

Importance  High-flow nasal oxygen may prevent postextubation respiratory failure in the intensive care unit (ICU). The combination of high-flow nasal oxygen with noninvasive ventilation (NIV) may be an optimal strategy of ventilation to avoid reintubation.

Objective  To determine whether high-flow nasal oxygen with prophylactic NIV applied immediately after extubation could reduce the rate of reintubation, compared with high-flow nasal oxygen alone, in patients at high risk of extubation failure in the ICU.

Design, Setting, and Participants  Multicenter randomized clinical trial conducted from April 2017 to January 2018 among 641 patients at high risk of extubation failure (ie, older than 65 years or with an underlying cardiac or respiratory disease) at 30 ICUs in France; follow-up was until April 2018.

Interventions  Patients were randomly assigned to high-flow nasal oxygen alone (n = 306) or high-flow nasal oxygen with NIV (n = 342) immediately after extubation.

Main Outcomes and Measures  The primary outcome was the proportion of patients reintubated at day 7; secondary outcomes included postextubation respiratory failure at day 7, reintubation rates up until ICU discharge, and ICU mortality.

Results  Among 648 patients who were randomized (mean [SD] age, 70 [10] years; 219 women [34%]), 641 patients completed the trial. The reintubation rate at day 7 was 11.8% (95% CI, 8.4%-15.2%) (40/339) with high-flow nasal oxygen and NIV and 18.2% (95% CI, 13.9%-22.6%) (55/302) with high-flow nasal oxygen alone (difference, −6.4% [95% CI, −12.0% to −0.9%]; P = .02). Among the 11 prespecified secondary outcomes, 6 showed no significant difference. The proportion of patients with postextubation respiratory failure at day 7 (21% vs 29%; difference, −8.7% [95% CI, −15.2% to −1.8%]; P = .01) and reintubation rates up until ICU discharge (12% vs 20%, difference −7.4% [95% CI, −13.2% to −1.8%]; P = .009) were significantly lower with high-flow nasal oxygen and NIV than with high-flow nasal oxygen alone. ICU mortality rates were not significantly different: 6% with high-flow nasal oxygen and NIV and 9% with high-flow nasal oxygen alone (difference, −2.4% [95% CI, −6.7% to 1.7%]; P = .25).

Conclusions and Relevance  In mechanically ventilated patients at high risk of extubation failure, the use of high-flow nasal oxygen with NIV immediately after extubation significantly decreased the risk of reintubation compared with high-flow nasal oxygen alone.

Trial Registration  ClinicalTrials.gov Identifier: NCT03121482

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