High-flow nasal cannula to prevent postextubation respiratory failure in high-risk non-hypercapnic patients: a randomized multicenter trial

Rafael Fernandez, Carles Subira, Fernando Frutos-Vivar, Gemma Rialp, Cesar Laborda, Joan Ramon Masclans, Amanda Lesmes, Luna Panadero, Gonzalo Hernandez, Rafael Fernandez, Carles Subira, Fernando Frutos-Vivar, Gemma Rialp, Cesar Laborda, Joan Ramon Masclans, Amanda Lesmes, Luna Panadero, Gonzalo Hernandez

Abstract

Background: Extubation failure is associated with increased morbidity and mortality, but cannot be safely predicted or avoided. High-flow nasal cannula (HFNC) prevents postextubation respiratory failure in low-risk patients.

Objective: To demonstrate that HFNC reduces postextubation respiratory failure in high-risk non-hypercapnic patients compared with conventional oxygen.

Methods: Randomized, controlled multicenter trial in patients who passed a spontaneous breathing trial. We enrolled patients meeting criteria for high-risk of failure to randomly receive HFNC or conventional oxygen for 24 h after extubation. Primary outcome was respiratory failure within 72-h postextubation. Secondary outcomes were reintubation, intensive care unit (ICU) and hospital lengths of stay, and mortality. Statistical analysis included multiple logistic regression models.

Results: The study was stopped due to low recruitment after 155 patients were enrolled (78 received high-flow and 77 received conventional oxygen). Groups were similar at enrollment, and all patients tolerated 24-h HFNC. Postextubation respiratory failure developed in 16 (20%) HFNC patients and in 21 (27%) conventional patients [OR 0.69 (0.31-1.54), p = 0.2]. Reintubation was needed in 9 (11%) HFNC patients and in 12 (16%) conventional patients [OR 0.71 (0.25-1.95), p = 0.5]. No difference was found in ICU or hospital length of stay, or mortality. Logistic regression models suggested HFNC [OR 0.43 (0.18-0.99), p = 0.04] and cancer [OR 2.87 (1.04-7.91), p = 0.04] may be independently associated with postextubation respiratory failure.

Conclusion: Our study is inconclusive as to a potential benefit of HFNC over conventional oxygen to prevent occurrence of respiratory failure in non-hypercapnic patients at high risk for extubation failure. Registered at Clinicaltrials.gov NCT01820507.

Keywords: High-flow oxygen; Mechanical ventilation; Reintubation; Weaning.

Figures

Fig. 1
Fig. 1
CONSORT flowchart of the study
Fig. 2
Fig. 2
Kaplan–Meier plot of 72-h postextubation failure in patients receiving HFNC versus conventional oxygen therapy. The difference did not reach statistical significance (p = 0.2)

References

    1. McConville JF, Kress JP. Weaning patients from the ventilator. N Engl J Med. 2012;367:2233–2239. doi: 10.1056/NEJMra1203367.
    1. Saugel B, Rakette P, Hapfelmeier A, Schultheiss C, Phillip V, Thies P, Treiber M, Einwächter H, von Werder A, Pfab R, Eyer F, Schmid RM, Huber W. Prediction of extubation failure in medical intensive care unit patients. J Crit Care. 2012;27:571–577. doi: 10.1016/j.jcrc.2012.01.010.
    1. Esteban A, Frutos-Vivar F, Muriel A, Ferguson ND, Peñuelas O, Abraira V, Raymondos K, Rios F, Nin N, Apezteguía C, Violi DA, Thille AW, Brochard L, González M, Villagomez AJ, Hurtado J, Davies AR, Du B, Maggiore SM, Pelosi P, Soto L, Tomicic V, D’Empaire G, Matamis D, Abroug F, Moreno RP, Soares MA, Arabi Y, Sandi F, Jibaja M, Amin P, Koh Y, Kuiper MA, Bülow HH, Zeggwagh AA, Anzueto A. Evolution of mortality over time in patients receiving mechanical ventilation. Am J Respir Crit Care Med. 2013;188:220–230. doi: 10.1164/rccm.201212-2169OC.
    1. Thille AW, Harrois A, Schortgen F, Brun-Buisson C, Brochard L. Outcomes of extubation failure in medical intensive care unit patients. Crit Care Med. 2011;39:2612–2618. doi: 10.1097/CCM.0b013e3182282a5a.
    1. Thille AW, Richard JCh, Brochard L. The decision to extubate in the intensive care unit. Am J Respir Crit Care Med. 2013;187:1294–1302. doi: 10.1164/rccm.201208-1523CI.
    1. Ricard JD. High flow nasal oxygen in acute respiratory failure. Minerva Anestesiol. 2012;78:836–841.
    1. Papazian L, Corley A, Hess D, Fraser JF, Frat JP, Guitton C, Jaber S, Maggiore SM, Nava S, Rello J, Ricard JD, Stephan F, Trisolini R, Azoulay E. Use of high-flow nasal cannula oxygenation in ICU adults: a narrative review. Intensive Care Med. 2016;42:1336–1349. doi: 10.1007/s00134-016-4277-8.
    1. Roca O, Riera J, Torres F, Masclans JR. High-flow oxygen therapy in acute respiratory failure. Respir Care. 2010;55:408–413.
    1. Maggiore SM, Idone FA, Vaschetto R, Festa R, Cataldo A, Antonicelli F, Montini L, De Gaetano A, Navalesi P, Antonelli M. Nasal high-flow versus venture mask oxygen therapy after extubation. Effects on oxygenation, comfort, and clinical outcome. Am J Respir Crit Care Med. 2014;190:282–288. doi: 10.1164/rccm.201402-0364OC.
    1. Rittayamai N, Tscheikuna J, Rujiwit P. High-flow nasal cannula versus conventional oxygen therapy after endotracheal extubation: a randomized crossover physiologic study. Respir Care. 2014;59:485–490. doi: 10.4187/respcare.02397.
    1. Riera J, Perez P, Cortes J, Roca O, Masclans JR, Rello J. Effect of high flow nasal cannula and body position on end-expiratory lung volume: a cohort study using electrical impedance tomography. Respir Care. 2013;58:589–596. doi: 10.4187/respcare.02086.
    1. Parke RL, McGuinness SP. Pressures delivered by nasal high flow therapy during all phases of the respiratory cycle. Respir Care. 2013;58:1621–1624. doi: 10.4187/respcare.02358.
    1. Lee JH, Rehder KJ, Williford L, Cheifetz IM, Turner DA. Use of high flow nasal cannula in critically ill infants, children and adults: a critical review of the literature. Intensive Care Med. 2013;39:247–257. doi: 10.1007/s00134-012-2743-5.
    1. Vargas F, Saint-Leger M, Boyer A, Bui NH, Hilbert G. Physiologic effects of high-flow nasal cannula oxygen in critical care subjects. Respir Care. 2015;60:1369–1376. doi: 10.4187/respcare.03814.
    1. Girault C, Breton L, Richard JC, Tamion F, Vandelet P, Aboab J, Leroy J, Bonmarchand G, Vandelet P, Aboba J. Mechanical effects of airway humidification devices in difficult-to-wean patients. Crit Care Med. 2003;31:1306–1311. doi: 10.1097/01.CCM.0000063284.92122.0E.
    1. Chanques G, Constantin JM, Sauter M, Jung B, Sebbane M, Verzilli D, Lefrant JY, Jaber S. Discomfort associated with underhumidified high-flow oxygen therapy in critically ill patients. Intensive Care Med. 2009;35:996–1003. doi: 10.1007/s00134-009-1456-x.
    1. Hernandez G, Vaquero C, González P, Subira C, Frutos-Vivar F, Rialp G, Laborda C, Colinas L, Cuena R, Fernandez R. Effect of postextubation high-flow nasal cannula vs conventional oxygen therapy on reintubation in low-risk patients. A randomized clinical trial. JAMA. 2016;315:1354–1361. doi: 10.1001/jama.2016.2711.
    1. Brotfain E, Zlotnik A, Schwartz A, Frenkel A, Koyfman L, Gruenbaum SE, Klein M. Comparison of the effectiveness of high flow nasal oxygen cannula vs. standard non-rebreather oxygen face mask in post-extubation intensive care unit patients. Isr Med Assoc J. 2014;16:718–722.
    1. Stéphan F, Barrucand B, Petit P, Rézaiguia-Delclaux S, Médard A, Delannoy B, Cosserant B, Flicoteaux G, Imbert A, Pilorge C, Bérard L, BiPOP Study Group High-flow nasal oxygen vs noninvasive positive airway pressure in hypoxemic patients after cardiothoracic surgery: a randomized clinical trial. JAMA. 2015;313:2331–2339. doi: 10.1001/jama.2015.5213.
    1. Corley A, Bull T, Spooner AJ, Barnett AG, Fraser JF. Direct extubation onto high-flow nasal cannulae post-cardiac surgery versus standard treatment in patients with a BMI ≥30: a randomised controlled trial. Intensive Care Med. 2015;41:887–894. doi: 10.1007/s00134-015-3765-6.
    1. Nava S, Gregoretti C, Fanfulla F, Squadrone E, Grassi M, Carlucci A, Beltrame F, Navalesi P. Noninvasive ventilation to prevent respiratory failure after extubation in high-risk patients. Crit Care Med. 2005;33:2465–2470. doi: 10.1097/01.CCM.0000186416.44752.72.
    1. Ferrer M, Sellares J, Valencia M, Carrillo A, Gonzalez G, Badia JR, Nicolas JM, Torres A. Non-invasive ventilation after extubation in hypercapnic patients with chronic respiratory disorders: randomised controlled trial. Lancet. 2009;374:1082–1088. doi: 10.1016/S0140-6736(09)61038-2.
    1. Brown CV, Daigle JB, Foulkrod KH, Brouillette B, Clark A, Czysz C, Martinez M, Cooper H. Risk factors associated with early reintubation in trauma patients: a prospective observational study. J Trauma. 2011;71:37–41. doi: 10.1097/TA.0b013e31821e0c6e.
    1. Thille AW, Boissier F, Ghezala HB, Razazi K, Mekontso-Dessap A, Brun-Buisson C. Risk factors for and prediction by caregivers of extubation failure in ICU patients: a prospective study. Crit Care Med. 2015;43:613–620. doi: 10.1097/CCM.0000000000000748.
    1. Hernandez G, Vaquero C, Garcia S, Villasclaras A, Pardo C, de la Fuente E, Cuena R, Gonzalez P, Fernandez R. High flow conditioned oxygen therapy for prevention of reintubation in critically ill patients: a preliminary cohort study. Int J Crit Care Emerg Med. 2015;1(2):1–6. doi: 10.23937/2474-3674/1510009.
    1. Esteban A, Frutos-Vivar F, Ferguson ND, Arabi Y, Apezteguía C, González M, Epstein SK, Hill NS, Nava S, Soares MA, D’Empaire G, Alía I, Anzueto A. Noninvasive positive-pressure ventilation for respiratory failure after extubation. N Engl J Med. 2004;350:2452–2460. doi: 10.1056/NEJMoa032736.
    1. Kang BJ, Koh Y, Lim CM, Huh JW, Baek S, Han M, Seo HS, Suh HJ, Seo GJ, Kim EY, Hong SB, Han M. Failure of high-flow nasal cannula therapy may delay intubation and increase mortality. Intensive Care Med. 2015;41:623–632. doi: 10.1007/s00134-015-3693-5.
    1. Ricard JD, Messika J, Sztrymf B, Gaudry S. Impact on outcome of delayed intubation with high-flow nasal cannula oxygen: is the device solely responsible? Intensive Care Med. 2015;41:1157–1158. doi: 10.1007/s00134-015-3766-5.
    1. Turner EL, Perel P, Clayton T, Edwards P, Hernández AV, Roberts I, Shakur H, Steyerberg EW, CRASH trial collaborators Covariate adjustment increased power in randomized controlled trials: an example in traumatic brain injury. J Clin Epidemiol. 2012;65:474–481. doi: 10.1016/j.jclinepi.2011.08.012.
    1. Glossop AJ, Shepherd N, Bryden DC, Mills GH. Non-invasive ventilation for weaning, avoiding reintubation after extubation and in the postoperative period: a meta-analysis. Br J Anaesthesia. 2012;109:305–314. doi: 10.1093/bja/aes270.
    1. Burns KE, Meade MO, Premji A, Adhikari NK. Noninvasive ventilation as a weaning strategy for mechanical ventilation in adults with respiratory failure: a Cochrane systematic review. CMAJ. 2014;186:E112–E122. doi: 10.1503/cmaj.130974.
    1. Hilbert G, Gruson D, Portel L, Gbikpi-Benissan G, Cardinaud JP. Noninvasive pressure support ventilation in COPD patients with postextubation hypercapnic respiratory insufficiency. Eur Respir J. 1998;11:1349–1353. doi: 10.1183/09031936.98.11061349.
    1. Itagaki T, Okuda N, Tsunano Y, Kohata H, Nakataki E, Onodera M, Imanaka H, Nishimura M. Effect of high-flow nasal cannula on thoraco-abdominal synchrony in adult critically ill patients. Respir Care. 2014;59:70–74. doi: 10.4187/respcare.02480.
    1. Sztrymf B, Messika J, Bertrand F, Hurel D, Leon R, Dreyfuss D, Ricard JD. Beneficial effects of humidified high flow nasal oxygen in critical care patients: a prospective pilot study. Intensive Care Med. 2011;37:1780–1786. doi: 10.1007/s00134-011-2354-6.

Source: PubMed

Sponsor e collaboratori

Condizioni mediche

Interventi farmacologici

3
Sottoscrivi