High-flow nasal oxygen may prevent postextubation respiratory failure in the intensive care unit (ICU). The combination of high-flow nasal oxygen with noninvasive ventilation (NIV) may be an optimal strategy of ventilation to avoid reintubation. OBJECTIVE To determine whether high-flow nasal oxygen with prophylactic NIV applied immediately after extubation could reduce the rate of reintubation, compared with high-flow nasal oxygen alone, in patients at high risk of extubation failure in the ICU. DESIGN, SETTING, AND PARTICIPANTS Multicenter randomized clinical trial conducted from April 2017 to January 2018 among 641 patients at high risk of extubation failure (ie, older than 65 years or with an underlying cardiac or respiratory disease) at 30 ICUs in France; follow-up was until April 2018. INTERVENTIONS Patients were randomly assigned to high-flow nasal oxygen alone (n = 306) or high-flow nasal oxygen alternating with NIV (n = 342) immediately after extubation. MAIN OUTCOMES AND MEASURESThe primary outcome was the proportion of patients reintubated at day 7; secondary outcomes included postextubation respiratory failure at day 7, reintubation rates up until ICU discharge, and ICU mortality. RESULTS Among 648 patients who were randomized (mean [SD] age, 70 [10] years; 219 women [34%]), 641 patients completed the trial. The reintubation rate at day 7 was 11.8% (95% CI, 8.4%-15.2%) (40/339) with high-flow nasal oxygen and NIV and 18.2% (95% CI, 13.9%-22.6%) (55/302) with high-flow nasal oxygen alone (difference, −6.4% [95% CI, −12.0% to −0.9%]; P = .02). Among the 11 prespecified secondary outcomes, 6 showed no significant difference. The proportion of patients with postextubation respiratory failure at day 7 (21% vs 29%; difference, −8.7% [95% CI, −15.2% to −1.8%]; P = .01) and reintubation rates up until ICU discharge (12% vs 20%, difference −7.4% [95% CI, −13.2% to −1.8%]; P = .009) were significantly lower with high-flow nasal oxygen and NIV than with high-flow nasal oxygen alone. ICU mortality rates were not significantly different: 6% with high-flow nasal oxygen and NIV and 9% with high-flow nasal oxygen alone (difference, −2.4% [95% CI, −6.7% to 1.7%]; P = .25). CONCLUSIONS AND RELEVANCEIn mechanically ventilated patients at high risk of extubation failure, the use of high-flow nasal oxygen with NIV immediately after extubation significantly decreased the risk of reintubation compared with high-flow nasal oxygen alone.
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can cause severe pneumonia requiring invasive mechanical ventilation [1], in the context of atypical acute respiratory distress syndrome (ARDS) [2]. The magnitude of the epidemic places an unprecedented pressure on intensive care units (ICUs), making avoidance of intubation a critical issue. Supplemental oxygen is the first-line treatment of ARDS. When escalation is needed, pre-intubation approaches carry the risk of delaying intubation and increasing mortality [3]. Noninvasive ventilation (NIV) is not recommended [4] but high-flow nasal oxygen (HFNO) may decrease the need for intubation without impacting mortality [4, 5]. Mostly because of an early negative report [6], continuous positive airway pressure (CPAP) remains largely undocumented in ARDS. In SARS-CoV-2 pneumonia, evidence-based guidelines are lacking [7] but CPAP could prove useful [8]. In this context, on 20 March, 2020, the French learned society for respiratory medicine circulated a clinical management algorithm derived from the Italian experience and suggesting the use of CPAP in SARS-CoV-2 patients requiring oxygen escalation [8]. This algorithm was implemented in our department on 24 March, 2020, in a context of limited HFNO availability and environmental contamination concerns. We designed this retrospective study to evaluate the impact of the CPAP strategy on intubation rate. We compared the period immediately before the algorithm implementation (11-23 March, 2020) with the period immediately after (24 March to 8 April), testing the hypothesis that CPAP can avoid intubation in patients with severe forms of SARS-CoV-2 pneumonia over the first week of their management. This observational study with short-term historical controls was conducted in the 25-bed pulmonology unit of a 1600-bed university hospital (Pitié-Salpêtrière, Paris, France). It was approved by the institutional review board of the French learned society for respiratory medicine (CEPRO2020-024). Patients were informed of the use of their anonymised data and given the opportunity to refuse it.
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