Prophylactic NIV and HFNO Reduce Postextubation Respiratory Failure in High-Risk Non-COPD Patients, Study Finds
France: In non-COPD patients at high risk of extubation failure, prophylactic noninvasive ventilation (NIV) alternating with high-flow nasal oxygen (HFNO) was significantly more effective in reducing post-extubation respiratory failure (PRF) compared to conventional oxygen therapy, the WIN IN WEAN multicenter randomized controlled trial has shown.
"However, it did not result in lower reintubation rates or mortality. Although the intervention required more resources, it proved as effective as rescue NIV in managing PRF," the researchers wrote. The findings were published online in Critical Care Journal on 26 November 2024.
Extubation is a critical step for ICU discharge, but 25% of high-risk patients experience post-extubation respiratory failure, with half requiring reintubation. Prophylactic NIV with high-flow nasal oxygen reduces PRF but does not lower reintubation rates. Lung ultrasound can predict PRF risk, helping to tailor extubation strategies.
Considering this, In the WIN IN WEAN randomized controlled trial, Jean-Jacques Rouby, Sorbonne University, GRC 29, DMU DREAM, Paris, France, and colleagues aimed to evaluate whether prophylactic NIV alternating with HFNO, compared to conventional oxygen, could reduce the incidence of PRF in non-COPD patients identified as high risk by a lung ultrasound score (LUS) ≥ 14 after a successful spontaneous breathing trial (SBT).
For this purpose, the researchers included ventilated patients without chronic obstructive pulmonary disease (COPD) and at high risk for PRF, defined by a LUS ≥ 14 during the spontaneous breathing trial, in a French-Chinese randomized controlled trial. PRF was characterized by two or more signs: SpO2 < 90%, respiratory rate > 30/min, hypercapnia, or hemodynamic and/or neurological disturbances of respiratory origin. The intervention group received prophylactic NIV alternating with HFNO for 48 hours after extubation, while the control group received conventional oxygen.
Clinicians were informed of the LUS in the intervention group, while those in the control group remained blinded. The primary outcome was the incidence of PRF 48 hours after extubation, with secondary outcomes including PRF and reintubation rates at day 7, number of ventilator-free days at day 28, length of ICU stay, and mortality at days 28 and 90.
The following were the key findings of the study:
- 240 patients were randomized, with 227 analyzed (128 in the intervention group and 99 in the control group).
- PRF at 48 hours was significantly reduced in the intervention group compared to the control group, with a relative risk of 0.52.
- The benefit of reduced PRF persisted at day 7, with a relative risk of 0.62.
- Weaning failure requiring reconnection to mechanical ventilation was not reduced.
- Among patients who developed PRF and received rescue NIV, reintubation was avoided in 44% of control and 12% of intervention patients.
- Other secondary outcomes showed no significant differences between the groups.
- Prophylactic NIV alternating with HFNO was more resource-intensive and costly compared to conventional oxygen with rescue NIV while achieving the same clinical outcomes.
"The findings showed that prophylactic NIV alternating with HFNO significantly reduced postextubation respiratory failure compared to conventional oxygenation in high-risk, non-COPD patients, but did not lower reintubation rates or mortality. This approach proved as effective as rescue NIV in treating postextubation respiratory failure," the researchers concluded.
Reference:
Rouby, JJ., Perbet, S., Quenot, JP. et al. Weaning of non COPD patients at high-risk of extubation failure assessed by lung ultrasound: the WIN IN WEAN multicentre randomised controlled trial. Crit Care 28, 391 (2024). https://doi.org/10.1186/s13054-024-05166-w
