Clinical practice guidelines recommend the use of noninvasive ventilation (NIV) to prevent postextubation respiratory failure in high-risk patients. However, most patients receive standard oxygen owing to an absence of randomized clinical trials showing a significant reduction of reintubation rates with NIV. A multicenter randomized clinical trial involving ICU patients at high risk for extubation failure was undertaken to determine whether high-flow nasal oxygen with NIV administered immediately after extubation could reduce the risk of reintubation compared with high-flow nasal oxygen alone.

Adults intubated more than 24 hours in the ICU and ready for extubation were enrolled if they were at high risk for extubation failure (that is, if they were older than age 65 or had underlying chronic cardiac or respiratory disease). The 641 patients included in the analysis were randomized to groups receiving high-flow nasal oxygen, either alone or in combination with NIV.

The reintubation rate at day 7, the primary outcome, was significantly lower among those given high-flow nasal oxygen with NIV compared with those receiving high-flow nasal oxygen alone (11.8% versus 18.2%). Reintubation rates at 48 hours, 72 hours, and until ICU discharge were also significantly lower among those who had high-flow nasal oxygen with NIV rather than high-flow nasal oxygen alone, as was the proportion of patients with postextubation respiratory failure at day 7. Mortality in the ICU, in the hospital, and at day 90 weren't significantly different between groups.

The authors note that attending physicians couldn't be blinded in this study, and the weaning protocol and type of spontaneous breathing trial performed before extubation may have influenced the results.