Expert Opinion on Post Extubation Oxygenation Strategies in Critically Ill & Postop Patients

Around 15% of patients ready to be weaned off a ventilator experience extubation failure leading to reintubation. The optimum oxygenation strategy for postoperative patients is different from that of extubated patients in the ICU.

For ICU patients:

With regards to the prevention of reintubation in patients at high risk of extubation failure the authors wrote, "The use of high-flow nasal oxygen and non-invasive ventilation are two alternatives of standard oxygen supplementation that may help to prevent reintubation."

They noted that high-flow nasal oxygen and non-invasive ventilation, may be used to prevent reintubation in patients with low (e.g., patients without comorbidities and with short duration of mechanical ventilation) and high risk (e.g., patients >65 years and those with underlying cardiac disease, chronic respiratory disorders, and/or hypercapnia at the time of extubation) of reintubation, respectively.

However, they also noted that the non-invasive ventilation which was used as a salvage therapy to treat existing respiratory failure after extubation should be used very carefully due to increased risk of mortality by delaying reintubation.

For Postoperative Patients:

The oxygenation strategy to be applied in postoperative patients is different from the patients who are extubated in the ICUs.

Based on literature findings they advised against the routine use of high-flow nasal oxygen in postoperative patients as the expected intubation rates were not exceeding around 5%; thus stating, "standard oxygen remains the reference treatment to be started immediately after major surgery".

They noted that standard oxygen is sufficient after a surgical procedure, even after major ones such as abdominal or cardiothoracic surgery (e.g., in patients with expected intubation rates around 5%).

However, they recommend switching to high-flow nasal oxygen if patients are hypoxic (e.g., patients with expected intubation rates around 10–15%) and further proceed with non-invasive ventilation in patients with respiratory failure with hypoxemia and high respiratory rate and/or clinical signs of respiratory distress (e.g., in patients with expected intubation rates reaching 50%).

The authors concluded,

• "Although high-flow nasal oxygen seems to be an effective alternative to standard oxygen in patients with low risk of extubation failure in ICUs, the prophylactic use of non-invasive ventilation should be proposed as the first-line strategy of oxygenation in patients with a high risk of failure.
• By contrast, standard oxygen seems sufficient in postoperative patients and high-flow nasal oxygen should be used in patients with hypoxemia.
• Non-invasive ventilation may decrease the risk of intubation in postoperative patients with respiratory failure, but it could increase the risk of death by delaying reintubation in patients with post-extubation respiratory failure in the ICU."

For further information:

DOI: https://doi.org/10.1016/j.jointm.2021.05.003