Protocolized Care Does Not Prevent Reintubation
Patricia Kritek, MD
A protocol to use either high-flow nasal cannula or noninvasive ventilation after extubation did not prevent reintubation.
Based on studies completed during the past 2 decades, many intensive care units (ICU) have adopted protocols to regularly assess readiness for extubation (Lancet 2008; 371:126). Once a patient passes a spontaneous breathing trial (SBT), practices vary widely. Although studies have shown benefit for extubation to noninvasive ventilation (NIV) and high-flow nasal cannula (HFNC; NEJM JW Gen Med Dec 1 2019 and JAMA 2019; 322:1465), the value of a protocol to implement one over the other has not been demonstrated.
Investigators at Vanderbilt randomized two ICUs to 3-month blocks of either protocolized postextubation support or usual care; 751 patients were included in the study. The protocol recommended NIV for patients with chronic obstructive pulmonary disease, obesity hypoventilation syndrome, chronic hypercarbia from other causes, or elevated partial pressure of carbon dioxide during SBTs; all other patients in the intervention group received HFNC. Median duration of intubation was 3 days, and most patients had at least one risk factor for reintubation.
Reintubation rates at 96 hours and ICU-free days were the same in both groups. Results were similar when adjusted for severity of illness and risk for reintubation. HFNC was used in nearly three quarters of patients in protocol-guided care and in only 3% of usual-care patients. NIV support was similar between groups (18% vs. 14%).
This study primarily demonstrates that protocolizing HFNC use does not lower reintubation rates. Use of NIV in this study did not differ between groups and most likely reflects local clinical practice for patients with hypercarbic respiratory failure. I don’t think that this means protocolized postextubation care has no benefit, but rather that the protocol should be more selective about who gets HFNC.
Casey JD et al. Protocolized postextubation respiratory support to prevent reintubation. Am J Respir Crit Care Med 2021 Aug 1; 204:294. (https://doi.org/10.1164/rccm.202009-3561OC)
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