Non-invasive ventilation alternating with high-flow nasal oxygen versus high-flow nasal oxygen alone after extubation in COPD patients: a post hoc analysis of a randomized controlled trial

Abstract

Background Several randomized clinical trials have shown that non-invasive ventilation (NIV) applied immediately after extubation may prevent reintubation in patients at high-risk of extubation failure. However, most of studies included patients with chronic respiratory disorders as well as patients without underlying respiratory disease. To date, no study has shown decreased risk of reintubation with prophylactic NIV after extubation among patients with chronic obstructive pulmonary disease (COPD). We hypothesized that prophylactic NIV after extubation may decrease the risk of reintubation in COPD patients as compared with high-flow nasal oxygen. We performed a post hoc subgroup analysis of COPD patients included in a multicenter, randomized, controlled trial comparing prophylactic use of NIV alternating with high-flow nasal oxygen versus high-flow nasal oxygen alone immediately after extubation. Results Among the 651 patients included in the original study, 150 (23%) had underlying COPD including 86 patients treated with NIV alternating with high-flow nasal oxygen and 64 patients treated with high-flow nasal oxygen alone. The reintubation rate was 13% (11 out of 86 patients) with NIV and 27% (17 out of 64 patients) with high-flow nasal oxygen alone [difference, − 14% (95% CI − 27% to − 1%); p = 0.03]. Whereas reintubation rates were significantly lower with NIV than with high-flow nasal oxygen alone at 72 h and until ICU discharge, mortality in ICU did not differ between groups: 6% (5/86) with NIV vs. 9% (6/64) with high-flow nasal oxygen alone [difference − 4% (95% CI − 14% to 5%); p = 0.40]. Conclusions In COPD patients, prophylactic NIV alternating with high-flow nasal oxygen significantly decreased the risk of reintubation compared with high-flow nasal oxygen alone. Trial registration The study was registered at http://www.clinicaltrials.gov with the trial registration number NCT03121482 (20 April 2017)

High-Flow Nasal Cannula Oxygen Therapy versus Non-Invasive Ventilation for AECOPD Patients After Extubation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

“…In the 8 RCT studies included,4 were in Chinese 17 , 18 , 20 , 23 and 4 were in English. 19 , 21 , 22 , 24 8 studies explicitly mentioned the method of generating random sequences, among which there are 4 items that mention allocation hiding. Due to differences in oxygen therapy equipment, it was difficult to blind study patients and interventionists.…”

“…A total of 710 relevant studies were initially detected, and after reading the literature titles and abstracts, they were screened according to the inclusion and exclusion criteria, and 8 qualified clinical studies were finally included, [17][18][19][20][21][22][23][24] a total of 612 subjects. There were 297 subjects in the HFNC group and 315 subjects in the NIV group.…”

“…All of the eight studies [17][18][19][20][21][22][23][24] reported the effect of HFNC on the reintubation rate of AECOPD patients after extubation, there are six studies [17][18][19][20]22,24 observed reintubation rate within 3 days and two studies 21,23 observed within 7 days (Figure 2), the heterogeneity test result was I 2 =27.7%, P=0.207, using a fixed effect model, the results showed RR (1.49 [95% CI,0.95 to 2.33], P=0.082), the difference was not statistically significant. Subgroup analysis was performed according to whether the included population was accompanied by hypercapnia.…”

“…Seven studies [17][18][19][20][21]23,24 reported the effect of HFNC on the mortality of AECOPD patients after extubation, four 17,19,20,24 of them reported 28 day mortality and three 18,21,23 of them reported mortality during hospitalization (Figure 3), the test result of the heterogeneity was I 2 =0.0%, P=0.939, using a fixed effect model, the results showed RR (0.92 [95% CI,0.56 to 1.52] P=0.752), the difference was not statistically significant. In subgroup analysis, with hypercapnia RR (1.09 [95% CI,0.55 to 2.14], P = 0.813), the difference was not statistically significant, without hypercapnia RR (0.77 [95% CI,0.37 to 1.61], P = 0.492), the difference was not statistically significant.…”

“…Six studies [17][18][19]21,23,24 reported the effect of HFNC and NIV on the ICU length of stay in days in patients with AECOPD after extubation (Figure 4), the heterogeneity test result was I 2 =87.4%, P= 0.00, using a random effects model, the results showed that MD (−0.44 [95% CI,-1.01 to 0.13], P=0.132), the difference was not statistically significant. In subgroup analysis, there was no statistically significant difference in MD with hypercapnia (−0.23 [95% CI,-0.51 to 0.05], P = 0.102), and without hypercapnia (−0.74 [95% CI,-2.16 to 0.69], P = 0.313).…”