High-flow nasal cannula oxygen therapy alone or with non-invasive ventilation during the weaning period after extubation in ICU: the prospective randomised controlled HIGH-WEAN protocol

Thille, Arnaud W.; Muller, Grégoire; Gacouin, Arnaud; Coudroy, Rémi; Demoule, Alexandre; Sonneville, Romain; Beloncle, François; Girault, Christophe; Dangers, Laurence; Lautrette, Alexandre; Cabasson, Séverin; Rouzé, Anahita; Vivier, Emmanuel; Meur, Anthony Le; Ricard, Jean‐Damien; Razazi, Keyvan; Barberet, Guillaume; Lebert, Christine; Ehrmann, Stéphan; Picard, Walter; Bourenne, Jérémy; Pradel, Gaël; Bailly, Pierre; Terzi, Nicolas; Buscot, Matthieu; Lacave, Guillaume; Danin, Pierre-Éric; Nanadoumgar, Hodanou; Gibelin, Aude; Zanre, Lassane; Deye, Nicolas; Ragot, Stéphanie; Frat, Jean‐Pierre

doi:10.1136/bmjopen-2018-023772

Cited by 13 publications

(2 citation statements)

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“…Two multicenter prospective randomized trials have demonstrated that HFNC could be better than COT [33] and not inferior to NIV [34] to prevent reintubation and post-extubation ARF in low- and high-risk patients, respectively. Results of the ongoing “High-Wean” trial comparing HFNC alone or with NIV in the post-extubation period for high-risk patients should give further evidence in this indication [35].…”

Section: Discussionmentioning

confidence: 99%

High-flow nasal cannula therapy: clinical practice in intensive care units

Besnier¹,

Hobeika²,

Nseir³

et al. 2019

Ann. Intensive Care

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Background Despite the extensive use of high-flow nasal cannula (HFNC) therapy in intensive care units (ICU) for acute respiratory failure (ARF), its daily clinical practice has not been assessed. We designed a regional survey in ICUs in North-west France to evaluate ICU physicians’ clinical practice with HFNC. Materials and methods We sent an observational survey to ICU physicians from 34 French ICUs over a 6-month period in 2016–2017. The survey included questions regarding the indications and expected efficiency of HFNC, practical aspects of use (initiation, weaning) and satisfaction. Comparisons between junior and senior ICU physicians were performed using a Fischer exact test. Results Among the 235 ICU physicians contacted, 137 responded (58.3%) all of whom regularly used HFNC. Hypoxemic ARF was considered a good indication for HFNC by all 137, but only 30% expected HFNC success (i.e., avoiding intubation in at least 60% of cases). Among hypoxemic indications, 30% of juniors considered acute pulmonary edema a good indication versus 74% of seniors ( p < 0.0001). Hypercapnic ARF was considered a good indication by 33% with only 2% expecting HFNC success. A need for conventional oxygen therapy ≥ 6 L/min justified HFNC therapy for 40% and ≥ 9 L/min for 39% of responders. 58% of ICU physicians started HFNC therapy with a FiO 2 ≥ 50% and 28% with a gas flow ≥ 50 L/min. Practices for HFNC weaning were heterogeneous: 48% considered a FiO 2 ≤ 30%; whereas, 30% considered a FiO 2 ≤ 30% with a high flow ≤ 20 L/min. Criteria for HFNC failure (i.e., need for intubation) were ventilatory pauses or arrest (97%), persistent hypoxemia (95%), respiratory acidosis (81%), worsening of breathing (95%, 100% of seniors and 86% of juniors, p = 0.003), bronchial congestion (75%) and circulatory failure (61%, 72% of seniors and 44% of juniors, p = 0.007). Conclusion HFNC is used by ICU physicians in many situations of ARF, despite their relatively low expectations of success, especially in cases of hypercapnia. Clinical practices appear somewhat heterogeneous. Despite the physiological benefit of HFNC, further prospective observational studies are still required on HFNC outcomes and daily practices.

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Section: Discussionmentioning

confidence: 99%

High-flow nasal cannula therapy: clinical practice in intensive care units

Besnier¹,

Hobeika²,

Nseir³

et al. 2019

Ann. Intensive Care

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“…After extubation, prophylactic use of non-invasive ventilation alternating with high-flow nasal oxygen between non-invasive ventilation sessions will be recommended in all patients for at least 48 hours according to the results of our previous study. 13 14…”

Section: Duration Of Treatment and Strategy Of Weaning And Extubationmentioning

confidence: 99%

T-piece versus pressure-support ventilation for spontaneous breathing trials before extubation in patients at high risk of reintubation: protocol for a multicentre, randomised controlled trial (TIP-EX)

et al. 2020

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IntroductionIn intensive care unit (ICU), the decision of extubation is a critical time because mortality is particularly high in case of reintubation. To reduce that risk, guidelines recommend to systematically perform a spontaneous breathing trial (SBT) before extubation in order to mimic the postextubation physiological conditions. SBT is usually performed with a T-piece disconnecting the patient from the ventilator or with low levels of pressure-support ventilation (PSV). However, work of breathing is lower during PSV than during T-piece. Consequently, while PSV trial may hasten extubation, it may also increase the risk of reintubation. We hypothesise that, compared with T-piece, SBT performed using PSV may hasten extubation without increasing the risk of reintubation.Methods and analysisThis study is an investigator-initiated, multicentre randomised controlled trial comparing T-piece vs PSV for SBTs in patients at high risk of reintubation in ICUs. Nine hundred patients will be randomised with a 1:1 ratio in two groups according to the type of SBT. The primary outcome is the number of ventilator-free days at day 28, defined as the number of days alive and without invasive mechanical ventilation between the initial SBT (day 1) and day 28. Secondary outcomes include the number of days between the initial SBT and the first extubation attempt, weaning difficulty, the number of patients extubated after the initial SBT and not reintubated within the following 72 hours, the number of patients extubated within the 7 days following the initial SBT, the number of patients reintubated within the 7 days following extubation, in-ICU length of stay and mortality in ICU, at day 28 and at day 90.Ethics and disseminationThe study has been approved by the central ethics committee ‘Ile de France V’ (2019-A02151-56) and patients will be included after informed consent. The results will be submitted for publication in peer-reviewed journals.Trial registration numberNCT04227639.

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