Effect of postextubation noninvasive ventilation with active humidification vs high-flow nasal cannula on reintubation in patients at very high risk for extubation failure: a randomized trial

Gonzalo Hernández, Irene Paredes, Francisco Moran, Marcos Buj, Laura Colinas, María Luisa Rodríguez, Alfonso Velasco, Patricia Rodríguez, María José Pérez-Pedrero, Fernando Suarez-Sipmann, Alfonso Canabal, Rafael Cuena, Lluis Blanch, Oriol Roca, Gonzalo Hernández, Irene Paredes, Francisco Moran, Marcos Buj, Laura Colinas, María Luisa Rodríguez, Alfonso Velasco, Patricia Rodríguez, María José Pérez-Pedrero, Fernando Suarez-Sipmann, Alfonso Canabal, Rafael Cuena, Lluis Blanch, Oriol Roca

Abstract

Purpose: High-flow nasal cannula (HFNC) oxygen therapy was noninferior to noninvasive ventilation (NIV) for preventing reintubation in a heterogeneous population at high-risk for extubation failure. However, outcomes might differ in certain subgroups of patients. Thus, we aimed to determine whether NIV with active humidification is superior to HFNC in preventing reintubation in patients with ≥ 4 risk factors (very high risk for extubation failure).

Methods: Randomized controlled trial in two intensive care units in Spain (June 2020‒June 2021). Patients ready for planned extubation with ≥ 4 of the following risk factors for reintubation were included: age > 65 years, Acute Physiology and Chronic Health Evaluation II score > 12 on extubation day, body mass index > 30, inadequate secretions management, difficult or prolonged weaning, ≥ 2 comorbidities, acute heart failure indicating mechanical ventilation, moderate-to-severe chronic obstructive pulmonary disease, airway patency problems, prolonged mechanical ventilation, or hypercapnia on finishing the spontaneous breathing trial. Patients were randomized to undergo NIV with active humidification or HFNC for 48 h after extubation. The primary outcome was reintubation rate within 7 days after extubation. Secondary outcomes included postextubation respiratory failure, respiratory infection, sepsis, multiorgan failure, length of stay, mortality, adverse events, and time to reintubation.

Results: Of 182 patients (mean age, 60 [standard deviation (SD), 15] years; 117 [64%] men), 92 received NIV and 90 HFNC. Reintubation was required in 21 (23.3%) patients receiving NIV vs 35 (38.8%) of those receiving HFNC (difference -15.5%; 95% confidence interval (CI) -28.3 to -1%). Hospital length of stay was lower in those patients treated with NIV (20 [12‒36.7] days vs 26.5 [15‒45] days, difference 6.5 [95%CI 0.5-21.1]). No additional differences in the other secondary outcomes were observed.

Conclusions: Among adult critically ill patients at very high-risk for extubation failure, NIV with active humidification was superior to HFNC for preventing reintubation.

Trial registration: ClinicalTrials.gov NCT04125342.

Keywords: Active humidification; High-flow nasal cannula; Noninvasive ventilation; Outcome; Reintubation; Weaning.

Conflict of interest statement

All authors have completed and submitted the ICMJE Form for disclosure of potential conflicts of interest. GH reported travel expenses and personal fees from Fisher & Paykel Healthcare Ltd. OR reported a research grant from Hamilton Medical AG, speaker fees from Hamilton Medical AG, Fisher&Paykel Healthcare Ltd, Aerogen Ltd and Ambu, and non-financial research support from Timpel; all outside the submitted work.

© 2022. Springer-Verlag GmbH Germany, part of Springer Nature.

Figures

Fig. 1
Fig. 1
Flowchart of participants in a study comparing postextubation noninvasive ventilation with active humidification vs high-flow oxygen therapy for preventing reintubation in very high-risk patients. MV mechanical ventilation; SBT spontaneous breathing trial; NIV noninvasive ventilation with active humidification; HFNC high-flow nasal cannula
Fig. 2
Fig. 2
Kaplan–Meier analysis of time from extubation to reintubation

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