Support protocol for ICU patients after extubation didn't reduce reintubation rates

The trial compared a respiratory therapist-driven protocol that provided noninvasive ventilation or high-flow nasal cannula to patients after extubation to usual care and found no significant differences.

For recently extubated patients, a respiratory support protocol did not reduce risk of reintubation, according to a recent trial.

The study enrolled 751 adults from the medical ICU of an academic medical center who underwent extubation from invasive mechanical ventilation from Oct. 1, 2017, to March 31, 2019. There were 359 patients assigned to the intervention of protocolized postextubation respiratory support—a respiratory therapist-driven protocol in which patients with suspected hypercapnia received noninvasive ventilation and patients without suspected hypercapnia received high-flow nasal cannula. The other 392 patients received usual care, which was postextubation management at the discretion of treating clinicians. The results were published by the American Journal of Respiratory and Critical Care Medicine on April 1.

Postextubation respiratory support was provided to many more patients in the intervention group than in the usual care group: 92.2% versus 16.8%. The difference was largely driven by higher use of high-flow nasal cannula under the protocolized care: 74.7% versus 2.8%. However, the rate of reintubation was not improved in the intervention group (15.9% vs. 13.3%; odds ratio, 1.23 [95% CI, 0.82 to 1.84]; P=0.32). The study authors concluded that their protocol for postextubation respiratory support did not prevent reintubation compared to usual care.

The strengths of the study included its size, as the authors believe it to be the largest trial yet of postextubation respiratory support. Limitations of the study include its single-center design. The authors added that “it remains possible that specific patients or groups may benefit from post-extubation respiratory support.” However, they acknowledged that almost 90% of patients “had at least one risk factor for reintubation and protocolized support did not appear to be more effective among patients at higher risk.”

The results show only that this protocol wasn't helpful in this patient population, the authors said. “Allowing treating clinicians to identify patients likely to benefit from post-extubation respiratory support may be as effective as a protocolized approach to post-extubation respiratory support,” they wrote. “The results of the trial could have been different had all patients in the intervention group received non-invasive ventilation, had the duration of post-extubation support been fixed or longer, or had higher flow rates been provided with [high-flow nasal cannula].”