High-flow nasal oxygen cannula vs. noninvasive mechanical ventilation to prevent reintubation in sepsis: a randomized controlled trial

Surat Tongyoo, Porntipa Tantibundit, Kiattichai Daorattanachai, Tanuwong Viarasilpa, Chairat Permpikul, Suthipol Udompanturak, Surat Tongyoo, Porntipa Tantibundit, Kiattichai Daorattanachai, Tanuwong Viarasilpa, Chairat Permpikul, Suthipol Udompanturak

Abstract

Background: High-flow nasal oxygen cannula (HFNC) and noninvasive mechanical ventilation (NIV) can prevent reintubation in critically ill patients. However, their efficacy in post-extubated sepsis patients remains unclear. The objective of this study was to compare the efficacy of HFNC vs. NIV to prevent reintubation in post-extubated sepsis patients.

Methods: We conducted a single-centre, prospective, open-labelled, randomised controlled trial at the medical intensive care unit of Siriraj Hospital, Mahidol University, Bangkok, Thailand. Sepsis patients who had been intubated, recovered, and passed the spontaneous breathing trial were enrolled and randomly assigned in a 1:1 ratio to receive either HFNC or NIV support immediately after extubation. The primary outcome was rate of reintubation at 72 h after extubation.

Results: Between 1st October 2017 and 31st October 2019, 222 patients were enrolled and 112 were assigned to the HFNC group and 110 to the NIV group. Both groups were well matched in baseline characteristics. The median [IQR] age of the HFNC group was 66 [50-77] vs. 65.5 [54-77] years in the NIV group. The most common causes of intubation at admission were shock-related respiratory failure (57.1% vs. 55.5%) and acute hypoxic respiratory failure (34.8% vs. 40.9%) in the HFNC and NIV groups, respectively. The duration of mechanical ventilation before extubation was 5 [3-8] days in the HFNC group vs. 5 [3-9] days in the NIV group. There was no statistically significant difference in the primary outcome: 20/112 (17.9%) in the HFNC group required reintubation at 72 h compared to 20/110 (18.2%) in the NIV group [relative risk (RR) 0.99: 95% confidence interval (CI) (0.70-1.39); P = 0.95]. The 28-day mortality was not different: 8/112 (7.1%) with HFNC vs. 10/110 (9.1%) with NIV (RR 0.88: 95% CI (0.57-1.37); P = 0.59).

Conclusions: Among sepsis patients, there was no difference between HFNC and NIV in the prevention of reintubation at 72 h after extubation. Clinical Trial Registration ClinicalTrials.gov Identifier: NCT03246893; Registered 11 August 2017; https://ichgcp.net/clinical-trials-registry/NCT03246893?term=surat+tongyoo&draw=2&rank=3.

Keywords: Extubation; Extubation failure; High flow nasal cannula; Non-invasive mechanical ventilation; Reintubation; Sepsis.

Conflict of interest statement

All authors declare that they have no competing interests.

© 2021. The Author(s).

Figures

Fig. 1
Fig. 1
Flow diagram illustrating the screening, enrolment, and randomisation of patients HFNC: High-flow nasal oxygen cannula; NIV: noninvasive mechanical ventilation
Fig. 2
Fig. 2
Kaplan–Meier analysis of time from extubation to reintubation. The cumulative reintubation probability was no different between HFNC group and the NIV group (log-rank P = 0.95). HFNC: High-flow nasal oxygen cannula; NIV: Noninvasive mechanical ventilation
Fig. 3
Fig. 3
Risk of reintubation at 72 h after extubation, according to subgroup. Subgroup analysis according to six patients’ characters. The location of square represents the relative risk and the size of square reflects the relative numbers in each subgroup. The horizontal bars represent 95% confidence intervals

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