Noninvasive ventilation linked to less extubation failure in patients with obesity
Noninvasive ventilation after extubation for critically ill patients with obesity led to less instances of treatment failure within 3 days compared with oxygen therapy, according to study results published in Lancet Respiratory Medicine.
“Our findings have important implications for informing clinicians and policy makers with respect to the most appropriate after-extubation strategy in critically ill patients with obesity,” Audrey De Jong, MD, PhD, doctor in the anesthesia and critical care department at Centre Hospitalier Universitaire Montpellier in France, and colleagues wrote. “Furthermore, centers should consider developing systematic noninvasive ventilation use and assess long-term outcomes after applying this extubation strategy in patients with obesity.”
In a multicenter, parallel group, randomized controlled trial, De Jong and colleagues analyzed 981 critically ill patients with obesity from 39 different ICUs in France who underwent extubation to observe the difference in outcomes between noninvasive ventilation (alternating with high-flow nasal oxygen [HFNO] or standard oxygen) and oxygen therapy (HFNO alone or standard oxygen alone) after extubation.
Researchers randomly assigned patients to receive noninvasive ventilation (n = 490; mean age, 61 years; 63% men) or oxygen therapy (n = 491; mean age, 61 years; 58% men), then they randomly assigned them again to determine the type of oxygen therapy. In the noninvasive ventilation group, patients took part in various 30-to-60-minute sessions, which had to add up to a minimum of 4 hours daily.
The researchers primarily looked for treatment failure during the 3-day period following the extubation procedure, of which failure was classified as reintubation for mechanical ventilation, switching to the other treatment option or premature discontinuation of treatment, all assessed by intention to treat. Additionally, they evaluated the effect of medical and surgical status, length of mechanical ventilation, type of admission, SARS-CoV-2 infection and method of oxygen delivery on this rate.
Treatment failure
More patients in the oxygen therapy group experienced treatment failure compared with the noninvasive ventilation group (26.5% vs. 13.5%; RR = 0.43; 95% CI, 0.31-0.6), and the noninvasive ventilation group had a smaller cumulative incidence of treatment failure (HR = 0.48; 95% CI, 0.36-0.64). Researchers noted that the main reason for this difference between groups was patients switching from oxygen therapy to noninvasive ventilation.
In terms of effect modifiers, researchers found that the treatment failure rate was not changed in the noninvasive ventilation group when factoring them in.
Reintubation rates
In addition to the primary outcome, researchers looked at reintubation within 3 days after the procedure between both groups in two analyses: intention to treat and post-hoc crossover.
The percentage of patients in the intention-to-treat analysis who received reintubation was comparable between those who received noninvasive ventilation (10%) and those who received oxygen therapy (12%), and there was no difference in the cumulative incidence of reintubation (HR = 0.8; 95% CI, 0.55-1.18) in this analysis.
However, in the post-hoc crossover, researchers found that fewer patients in the noninvasive ventilation group (n = 560) underwent reintubation compared with the oxygen therapy group (n = 421; 9% vs. 13%; P = .037), and the cumulative incidence of reintubation was also lower for these patients after accounting for the 70 patients who switched into the group (HR = 0.67; 95% CI, 0.46-0.97).
Crossover from the oxygen therapy group to the noninvasive ventilation group took place 29 hours after researchers randomly assigned patients to their treatment group.
Researchers did not observe any death or cardiac arrest in their study population.
“For routine management following extubation of critically ill patients with obesity, using noninvasive ventilation is safe and decreases treatment failure within 72 hours,” De Jong and colleagues wrote. “HFNO should not replace noninvasive ventilation for preventing reintubation in the specific population of critically ill patients with obesity. Most of the difference in the primary outcome was due to patients in the oxygen therapy group switching to noninvasive ventilation, and more evidence is needed to conclude that a noninvasive ventilation strategy leads to improved patient-centered outcomes.”
Putting findings into practice
This study by De Jong and colleagues adds significant findings to the literature on after-extubation care for patients with obesity, and the study design should encourage clinicians to adopt noninvasive ventilation, according to an accompanying editorial by Dean R. Hess, PhD, RRT, FAARC, assistant director of the respiratory care department at Massachusetts General Hospital.
“For those in practice for many years, intermittent noninvasive ventilation might seem like intermittent positive pressure breathing (IPPB), a therapy abandoned because it has shown little benefit,” Hess wrote. “However, intermittent noninvasive ventilation as used in the EXTUB-OBESE study is distinctly different from IPPB. First, it uses positive end-expiratory pressure, which was not used with IPPB. Second, it uses an oronasal mask rather than a mouthpiece. Finally, it uses pressure support applied with a sophisticated ventilator rather than a simple pressure cycled IPPB machine. Intermittent noninvasive ventilation is applied for 30 minutes to 60 minutes for an accumulated time of at least 4 hours per day, whereas IPPB was administered briefly for 15-minute sessions four times per day.”