High-flow nasal cannula oxygen therapy and noninvasive ventilation for preventing extubation failure during weaning from mechanical ventilation assessed by lung ultrasound score: A single-center randomized study

doi:10.5847/wjem.j.1920-8642.2021.04.004

Abstract

Abstract:

BACKGROUND: We sought to demonstrate the superiority of a targeted therapy strategy involving high-flow nasal cannula oxygen (HFNCO₂) therapy and noninvasive ventilation (NIV) using lung ultrasound score (LUS) in comparison with standard care among patients in the intensive care unit (ICU) who undergo successful weaning to decrease the incidence of extubation failure at both 48 hours and seven days.
METHODS: During the study period, 98 patients were enrolled in the study, including 49 in the control group and 49 in the treatment group. Patients in the control group and patients with an LUS score <14 points (at low risk of extubation failure) in the treatment group were extubated and received standard preventive care without NIV or HFNCO₂. Patients with an LUS score ≥14 points (at high risk of extubation failure) in the treatment group were extubated with a second review of the therapeutic optimization to identify and address any persisting risk factors for postextubation respiratory distress; patients received HFNCO₂ therapy combined with sessions of preventive NIV (4-8 hours per day for 4-8 sessions total) for the first 48 hours after extubation.
RESULTS: In the control group, 13 patients had the LUS scores ≥14 points, while 36 patients had scores <14 points. In the treatment group, 16 patients had the LUS scores ≥14 points, while 33 patients had scores <14 points. Among patients with the LUS score ≥14 points, the extubation failure rate within 48 hours was 30.8% in the control group and 12.5% in the treatment group, constituting a statistically significant difference (P<0.05). Conversely, among patients with an LUS score <14 points, 13.9% in the control group and 9.1% in the treatment group experienced extubation failure (P=0.61). The length of ICU stay (9.4±3.1 days vs. 7.2±2.4 days) was significantly different and the re-intubation rate (at 48 hours: 18.4% vs. 10.2%; seven days: 22.4% vs. 12.2%) significantly varied between the two groups (P<0.05). There was no significant difference in the 28-day mortality rate (6.1% vs. 8.2%) between the control and treatment groups.
CONCLUSIONS: Among high-risk adults being weaned from mechanical ventilation and assessed by LUS, the NIV+HFNCO₂ protocol does not lessen the mortality rate but reduce the length of ICU stay, the rate of extubation failure at both 48 hours and seven days.

Key words: High-flow nasal cannula oxygen, Noninvasive ventilation, Lung ultrasound, Extubation

Shan-xiang Xu, Chun-shuang Wu, Shao-yun Liu, Xiao Lu. High-flow nasal cannula oxygen therapy and noninvasive ventilation for preventing extubation failure during weaning from mechanical ventilation assessed by lung ultrasound score: A single-center randomized study[J]. World Journal of Emergency Medicine, 2021, 12(4): 274-280.

Figures/Tables 4

Figure 1.

Table 1

Table 2

Table 3

References 32

1	Peñuelas O, Frutos-Vivar F, Fernández C, Anzueto A, Epstein SK, Apezteguía C, et al. Characteristics and outcomes of ventilated patients according to time to liberation from mechanical ventilation. Am J Respir Crit Care Med. 2011; 184(4):430-7. doi: 10.1164/rccm.201011-1887OC
2	Esteban A, Anzueto A, Frutos F, Alía I, Brochard L, Stewart TE, et al. Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study. JAMA. 2002; 287(3):345-55. doi: 10.1001/jama.287.3.345
3	Boles JM, Bion J, Connors A, Herridge M, Marsh B, Melot C, et al. Weaning from mechanical ventilation. Eur Respir J. 2007; 29(5):1033-56. pmid: 17470624
4	Bouhemad B, Liu ZH, Arbelot C, Zhang M, Ferarri F, Le-Guen M, et al. Ultrasound assessment of antibiotic-induced pulmonary reaeration in ventilator-associated pneumonia. Crit Care Med. 2010; 38(1):84-92. doi: 10.1097/CCM.0b013e3181b08cdb pmid: 19633538
5	Bouhemad B, Brisson H, Le-Guen M, Arbelot C, Lu Q, Rouby JJ. Bedside ultrasound assessment of positive end-expiratory pressure-induced lung recruitment. Am J Respir Crit Care Med. 2011; 183(3):341-7. doi: 10.1164/rccm.201003-0369OC
6	Wang YM, Zheng YJ, Chen Y, Huang YC, Chen WW, Ji R, et al. Effects of fluid balance on prognosis of acute respiratory distress syndrome patients secondary to sepsis. World J Emerg Med. 2020; 11(4):216-22. doi: 10.5847/wjem.j.1920-8642.2020.04.003
7	Bouhemad B, Zhang M, Lu Q, Rouby JJ. Clinical review: bedside lung ultrasound in critical care practice. Crit Care. 2007; 11(1):205. pmid: 17316468
8	Lichtenstein D, Goldstein I, Mourgeon E, Cluzel P, Grenier P, Rouby JJ. Comparative diagnostic performances of auscultation, chest radiography, and lung ultrasonography in acute respiratory distress syndrome. Anesthesiology. 2004; 100(1):9-15. pmid: 14695718
9	Huang HW, Sun XM, Shi ZH, Chen GQ, Chen L, Friedrich JO, et al. Effect of high-flow nasal Cannula oxygen therapy versus conventional oxygen therapy and noninvasive ventilation on reintubation rate in adult patients after extubation: a systematic review and meta-analysis of randomized controlled trials. J Intensive Care Med. 2018; 33(11):609-23. doi: 10.1177/0885066617705118 pmid: 28429603
10	Hernández G, Vaquero C, Colinas L, Cuena R, González P, Canabal A, et al. Effect of postextubation high-flow nasal Cannula vs noninvasive ventilation on reintubation and postextubation respiratory failure in high-risk patients: a randomized clinical trial. JAMA. 2016; 316(15):1565-74. doi: 10.1001/jama.2016.14194 pmid: 27706464
11	Spoletini G, Garpestad E, Hill NS. High-flow nasal oxygen or noninvasive ventilation for postextubation hypoxemia: flow vs pressure? JAMA. 2016; 315(13):1340-2. doi: 10.1001/jama.2016.2709 pmid: 26976699
12	Martins Tomazini B, Besen BAMP. High-flow oxygen vs noninvasive ventilation for postextubation respiratory failure. JAMA. 2017; 317(8):855. doi: 10.1001/jama.2016.20986 pmid: 28245313
13	Jubran A, Lawm G, Kelly J, Duffner LA, Gungor G, Collins EG, et al. Depressive disorders during weaning from prolonged mechanical ventilation. Intensive Care Med. 2010; 36(5):828-35. doi: 10.1007/s00134-010-1842-4 pmid: 20232042
14	Maggiore SM, Idone FA, Vaschetto R, Festa R, Cataldo A, Antonicelli F, et al. Nasal high-flow versus venturi mask oxygen therapy after extubation. Effects on oxygenation, comfort, and clinical outcome. Am J Respir Crit Care Med. 2014; 190(3):282-8. doi: 10.1164/rccm.201402-0364OC
15	Antonicelli F, Cataldo A, Festa R, Idone F, Moccaldo A, Antonelli M, et al. High-flow oxygen therapy through nasal cannulae versus low-flow oxygen therapy via Venturi mask after extubation in adult, critically ill patients. Crit Care. 2011; 15(suppl 1):165. doi: 10.1186/cc10238
16	Bell N, Hutchinson CL, Green TC, Rogan E, Bein KJ, Dinh MM. Randomised control trial of humidified high flow nasal cannulae versus standard oxygen in the emergency department. Emerg Med Australas. 2015; 27(6):537-41. doi: 10.1111/1742-6723.12490
17	Spoletini G, Garpestad E, Hill NS. High-flow nasal oxygen or noninvasive ventilation for postextubation hypoxemia: flow vs pressure? JAMA. 2016; 315(13):1340-2. doi: 10.1001/jama.2016.2709 pmid: 26976699
18	Kulkarni AP, Agarwal V. Extubation failure in intensive care unit: predictors and management. Indian J Crit Care Med. 2008; 12(1):1-9. doi: 10.4103/0972-5229.40942
19	Torres A, Gatell JM, Aznar E, El-Ebiary M, Puig de la Bellacasa J, González J, et al. Re-intubation increases the risk of nosocomial pneumonia in patients needing mechanical ventilation. Am J Respir Crit Care Med. 1995; 152(1):137-41. doi: 10.1164/ajrccm.152.1.7599812
20	Vassilakopoulos T. Ventilator-induced diaphragm dysfunction: the clinical relevance of animal models. Intensive Care Med. 2008; 34(1):7-16. doi: 10.1007/s00134-007-0866-x
21	Petrof BJ, Jaber S, Matecki S. Ventilator-induced diaphragmatic dysfunction. Curr Opin Crit Care. 2010; 16(1):19-25. doi: 10.1097/MCC.0b013e328334b166 pmid: 19935062
22	Coudroy R, Marjanovic N, Frat JP, Thille AW. Beneficial effects of noninvasive ventilation in acute hypoxemic respiratory failure: caution with findings from meta-analyses. Crit Care Med. 2017; 45(10):e1100-e1101. doi: 10.1097/CCM.0000000000002567
23	Fernandez R, Subira C, Frutos-Vivar F, Rialp G, Laborda C, Masclans JR, et al. High-flow nasal Cannula to prevent postextubation respiratory failure in high-risk non-hypercapnic patients: a randomized multicenter trial. Ann Intensive Care. 2017; 7(1):47. doi: 10.1186/s13613-017-0270-9 pmid: 28466461
24	Ou X, Hua Y, Liu J, Gong C, Zhao W. Effect of high-flow nasal Cannula oxygen therapy in adults with acute hypoxemic respiratory failure: a meta-analysis of randomized controlled trials. CMAJ. 2017; 189(7):E260-7. doi: 10.1503/cmaj.160570
25	Kuang ZS, Yang YL, Wei W, Wang JL, Long XY, Li KY, et al. Clinical characteristics and prognosis of community-acquired pneumonia in autoimmune disease-induced immunocompromised host: a retrospective observational study. World J Emerg Med. 2020; 11(3):145-51. doi: 10.5847/wjem.j.1920-8642.2020.03.003
26	Burns KE, Adhikari NK, Keenan SP, Meade M. Use of non-invasive ventilation to wean critically ill adults off invasive ventilation: meta-analysis and systematic review. BMJ. 2009; 338:b1574. doi: 10.1136/bmj.b1574
27	Girault C, Bubenheim M, Abroug F, Diehl JL, Elatrous S, Beuret P, et al. Noninvasive ventilation and weaning in patients with chronic hypercapnic respiratory failure: a randomized multicenter trial. Am J Respir Crit Care Med. 2011; 184(6):672-9. doi: 10.1164/rccm.201101-0035OC
28	Chiumello D, Chevallard G, Gregoretti C. Non-invasive ventilation in postoperative patients: a systematic review. Intensive Care Med. 2011; 37(6):918-29. doi: 10.1007/s00134-011-2210-8 pmid: 21424246
29	Su CL, Chiang LL, Yang SH, Lin HI, Cheng KC, Huang YC, et al. Preventive use of noninvasive ventilation after extubation: a prospective, multicenter randomized controlled trial. Respir Care. 2012; 57(2):204-10.
30	Ambrosino N, Vagheggini G. Noninvasive positive pressure ventilation in the acute care setting: where are we? Eur Respir J. 2008; 31(4):874-86. doi: 10.1183/09031936.00143507 pmid: 18378782
31	Esteban A, Frutos-Vivar F, Ferguson ND, Arabi Y, Apezteguía C, González M, et al. Noninvasive positive-pressure ventilation for respiratory failure after extubation. N Engl J Med. 2004; 350(24):2452-60. doi: 10.1056/NEJMoa032736
32	Keenan SP, Powers C, McCormack DG, Block G. Noninvasive positive-pressure ventilation for postextubation respiratory distress. JAMA. 2002; 287(24):3238. doi: 10.1001/jama.287.24.3238

Parameter	All patients (n=98)	Control group (n=49)	Treatment group (n=49)	P-value
Age (years)	45±14	47±10	44±15	0.36
Sex (male/female)	52/47	28/20	24/27	0.43
BMI (kg/m²)	21.4±2.4	21.8±4.4	20.2±2.5	0.41
SOFA score	11.1±2.2	10.1±3.1	11.7±2.7	0.33
LUS	12.1±3.1	11.3±3.3	12.6±2.6	0.71
Reason for ventilation/intubation, n (%)
Severe trauma	51 (52.0)	23 (46.9)	28 (57.1)
Surgical emergency	22 (22.4)	12 (24.5)	10 (20.4)
Pneumonia	12 (12.2)	7 (14.3)	5 (10.2)
Extrapulmonary sepsis	4 (4.1)	1 (2.0)	3 (6.1)
Aspiration or drowning	5 (5.1)	2 (4.1)	3 (6.1)
Other	4 (4.1)	2 (4.1)	2 (4.1)
Re-intubation rate within 48 hours, n (%)	14 (14.3)	9 (18.4)	5 (10.2)	<0.05
Re-intubation rate within seven days, n(%)	17 (17.3)	11 (22.4)	6 (12.2)	<0.05
Time of ICU stay (days)	8.5±3.5	9.4±3.1	7.2±2.4	<0.05
Duration of invasive mechanical ventilation before inclusion (days)	6.4±1.7	6.5±1.4	6.2±2.1	0.73
28-day mortality, n (%)	7 (7.1)	3 (6.1)	4 (8.2)	0.87

Variables	Control group (n=13)	Treatment group (n=16)	P-value
H0 (end of weaning trial)
Respiratory rate, breaths/minute	27±5	26±5	0.67
Pulse rate, beats/minute	105±13	110±11	0.43
MAP, mmHg	69±11	72±8	0.64
pH	7.33±0.21	7.37±0.5	0.44
PaCO₂, mmHg	43.7±4.8	44.2±6.1	0.76
PaO₂/FiO₂	213.6±27.5	225.5±32.8	0.25
SPO₂, %	95.1±2.1	96.2±2.2	0.47
H24 (24 hours after extubation)
Respiratory rate, breaths/minute	23±2	20±2	<0.05
Pulse rate, beats/minute	109±12	94±11	<0.05
MAP, mmHg	77±13	82±12	0.33
pH	7.41±0.21	7.39±0.13	0.32
PaCO₂, mmHg	41.3±3.7	38.1±3.1	0.45
PaO₂/FiO₂	205.5±38.1	225.8±54.6	<0.01
SPO₂, %	94.8±2.6	97.9±1.1	<0.05
H48 (48 hours after extubation)
Respiratory rate, breaths/minute	25±3	19±4	<0.05
Pulse rate, beats/minute	110±18	87±12	<0.05
MAP, mmHg	79±8	81±9	0.56
pH	7.44±0.14	7.41±0.16	0.24
PaCO₂, mmHg	41.0±5.7	38.9±9.9	0.96
PaO₂/FiO₂	207.3±43.9	262.6±59.1	<0.01
SPO₂, %	95.4±2.6	97.7±1.9	<0.05

Variables	Control group (n=36)	Treatment group (n=33)	P-value
H0 (end of weaning trial)
Respiratory rate, breaths/minute	23±5	25±4	0.33
Pulse rate, beats/minute	98±13	103±15	0.78
MAP, mmHg	73±10	78±11	0.25
pH	7.36±0.31	7.33±0.25	0.44
PaCO₂, mmHg	42.1±3.5	39.2±6.1	0.36
PaO₂/FiO₂	189.6±45.5	194.5±41.3	0.57
SPO₂, %	96.2±3.1	97.1±2.2	0.38
H24 (24 hours after extubation)
Respiratory rate, breaths/minute	23±5	24±4	0.65
Pulse rate, beats/minute	111±16	109±15	0.33
MAP, mmHg	75±7	77±11	0.42
pH	7.31±0.55	7.34±0.45	0.56
PaCO₂, mmHg	46.4±4.7	47.7±6.1	0.45
PaO₂/FiO₂	200.1±78.6	192.8±44.6	0.67
SPO₂, %	97.2±2.1	96.1±3.2	0.35
H48 (48 hours after extubation)
Respiratory rate, breaths/minute	22±4	21±4	0.57
Pulse rate, beats/minute	89±12	93±11	0.45
MAP, mmHg	78±7	80±7	0.78
pH	7.44±0.25	7.39±0.34	0.66
PaCO₂, mmHg	41.1±3.3	45.9±3.4	0.13
PaO₂/FiO₂	214.1±67.9	211.6±45.8	0.76
SPO₂, %	98.1±1.4	98.0±1.2	0.88

[1]	Xue-xue Pu, Jiong Wang, Xue-bo Yan, Xue-qin Jiang. Sequential invasive-noninvasive mechanical ventilation weaning strategy for patients after tracheostomy [J]. World Journal of Emergency Medicine, 2015, 6(3): 196-200.
[2]	Rong-rong Song, Yan-ping Qiu, Yong-ju Chen, Yong Ji. Application of fiberoptic bronchscopy in patients with acute exacerbations of chronic obstructive pulmonary disease during sequential weaning of invasive-noninvasive mechanical ventilation [J]. World Journal of Emergency Medicine, 2012, 3(1): 29-34.
[3]	Huan Huang, Xin-hui Xu, Yi Chen, Li-xiong Lu, Chang-qing Zhu. Early tracheotomy for acute severe asthma [J]. World Journal of Emergency Medicine, 2011, 2(2): 154-156.