Effect of Postextubation High-Flow Nasal Cannula vs Noninvasive Ventilation on Reintubation and Postextubation Respiratory Failure in High-Risk Patients: A Randomized Clinical Trial

In acute respiratory failure, HFNO was noninferior to NIV for endotracheal intubation or death at 7 d in 4 of 5 patient subgroups

CLINICAL IMPACT RATINGS

Emergency Med: [Formula: see text] GIM/FP/GP: [Formula: see text] Cardiology: [Formula: see text] Critical Care: [Formula: see text] Pulmonology: [Formula: see text].

Comparison of ROX index with modified indices incorporating heart rate, flow rate, and PaO2/FiO2 ratio for early prediction of outcomes among patients initiated on post-extubation high-flow nasal cannula therapy

BACKGROUND

Incorporation of heart rate, flow rate, and PaO2/FIO2 (PF) ratio to ROX index has been postulated to better predict high-flow nasal cannula (HFNC) usage outcomes in post-extubation setting. Therefore, we aimed to compare ROX index with new modified indices to predict HFNC outcomes in the post-extubation setting.

METHODS

This single-centre 6-year retrospective study included subjects initiated on HFNC post-extubation. The modified indices (ROX-HR, ROX-HR-Flow and POX-HR-Flow) incorporated HFNC flow rate, heart rate and substituted PF ratio for SF ratio. Evaluation was performed using AUROC and cut-offs assessed for prediction of HFNC outcomes.

RESULTS

Eighty-one subjects were initiated on HFNC post-extubation, of whom 67 patients (82.7%) had HFNC success. ROX-HR-Flow at 2 h post-HFNC initiation demonstrated the best prediction accuracy (AUROC 0.854, 95% CI 0.756-0.952). A ROX-HR-Flow > 12.25 at 2 h post-HFNC initiation was significantly associated with a lower risk of HFNC failure (Sensitivity 77.6% and Specificity 85.7%).

CONCLUSIONS

Our proposed modified index at 2 h post-HFNC initiation (ROX-HR-Flow), may facilitate early and accurate prediction of HFNC outcomes compared to ROX index among subjects initiated on HFNC in the post-extubation setting.

High-Fidelity Simulation Curriculum for Training Residents in Noninvasive Respiratory Support

Background: The coronavirus disease (COVID-19) pandemic highlighted the importance of physicians managing patients with noninvasive respiratory support (NIRS), including noninvasive ventilation (NIV) and high-flow nasal cannulas (HFNCs), emphasizing the need for thorough education on these modalities. Objective: To determine the effect of a novel simulation-based curriculum on improving the equipment familiarity and understanding of the physiology and application of NIRS among internal medicine residents. Methods: The curriculum consisted of a didactic session on the clinical application of NIRS, a case-based scenario on NIV using high-fidelity simulation, and a debrief session. Learners filled out surveys before and after the session to evaluate changes in objective knowledge of and subjective comfort with NIRS. P values were calculated using independent two-sample t tests. Results: Most residents (85.6%; n = 101) confirmed never having received a formal training in NIRS. At baseline, 34.7% (n = 41) and 24.6% (n = 29) felt "comfortable" or "very comfortable," respectively, using NIRS, which improved to 91.5% (n = 108) and 89% (n = 105) after the session (P = 0.001). A statistically significant improvement in clinical knowledge was demonstrated after the session (P < 0.05), with residents correctly recognizing all three indications for bilevel positive airway pressure (BiPAP) (87.2% to 98.3%, 56% to 67.8%, and 21.2% to 55.1%), contraindications to BiPAP (81.4% to 90.7%), appropriate adjustment of BiPAP (30.5% to 73.7%), and HFNC settings (68.6% to 79.7%). Following the curriculum, postgraduate year (PGY)-1 (PGY-1)s' knowledge was increased beyond the baseline of the PGY-2/3s who trained in New York during the pandemic (mean score change 50.6% to 72.1% for PGY-1s, 61.5% to 75.7% for PGY-2/3s). Three-month retention surveys revealed consistent learner satisfaction and learner retention in all aspects. Conclusion: Our 1-hour high-fidelity simulation-based curriculum significantly enhanced medical residents' knowledge, skills, and confidence in using NIRS for acute respiratory failure, with particularly notable benefits for those in the early years of training. Such a simulation-based curriculum could potentially lead to better hospital resource allocation and improved patient outcomes.

How to prevent postextubation respiratory failure

PURPOSE OF REVIEW

Postextubation respiratory support treatment approaches, indications, and subgroups of patients with different responses to those therapies are rapidly changing. Planning optimal therapy in terms of choosing devices, timing of application and selecting settings with the goal of minimizing extubation failure is becoming a challenge. This review aims to analyze all the available evidence from a clinical point of view, trying to facilitate decision making at the bedside.

RECENT FINDINGS

There is evidence for high flow nasal cannula support in patients at low risk of extubation failure. Noninvasive ventilation based strategies should be prioritized in patients at very high risk, who are obese or are hypercapnic at the end of a spontaneous breathing trial. Patients not included in the previous groups merit a tailored decision based on more variables.Optimizing the timing of therapy can include facilitation of extubation by transitioning to noninvasive respiratory support or prolonging a planned preventive therapy according to clinical condition.

SUMMARY

Planning postextubatin respiratory support must consider the risk for failing and the presence of some clinical conditions favoring noninvasive ventilation.Extubation can be safely accelerated by modifying screening criteria and spontaneous breathing trial settings, but there is room to increase the role of postextubation noninvasive respiratory support for this indication, always keeping in mind the dangers of delaying a needed intubation.

Early weaning from invasive mechanical ventilation via high-flow nasal oxygen versus conventional weaning in patients with hypoxemic respiratory failure: a prospective randomized controlled study

OBJECTIVE

Although the efficacy of high-flow nasal oxygen therapy in delaying or avoiding intubation in patients with hypoxemic respiratory failure has been studied, its potential for facilitating early weaning from invasive mechanical ventilation remains unexplored.

METHODS

In this randomized controlled trial, 80 adults with acute hypoxemic respiratory failure requiring invasive mechanical ventilation for > 48 hours were enrolled and divided into two groups: conventional weaning and early weaning via high-flow nasal oxygen. In the conventional weaning group, the spontaneous breathing trial was performed after the PaO2/FiO2 ratio was ≥ 200, whereas in the high-flow nasal oxygen group, the spontaneous breathing trial was conducted earlier when the PaO2/FiO2 ratio was 150 - 200. Following each successful spontaneous breathing trial, patients were extubated and put on oxygen supplementation via a venturi mask or high-flow nasal oxygen on the basis of their group allocation. The primary objective was to compare extubation failure (reintubation within 48 hours). The secondary objectives were to compare total invasive mechanical ventilation, oxygen requirement and sedation requirement days, ventilator-associated pneumonia incidence, invasive mechanical ventilation-free days, intensive care unit length of stay, and intensive care unit all-cause mortality.

RESULTS

Extubation failure was not significantly different between the high-flow nasal oxygen group and the conventional weaning group [12.5% versus 25%, respectively; odds ratio (95%CI) 0.5 (0.19 - 1.33)] (p = 0.25). Early weaning from invasive mechanical ventilation via high-flow nasal oxygen was associated with significantly increased invasive mechanical ventilation-free days and total oxygen requirement days (p = 0.02 and p = 0.01, respectively). No significant between-group differences were observed in total invasive mechanical ventilation days, ventilator-associated pneumonia incidence, intensive care unit length of stay, sedation duration, or all-cause mortality.

CONCLUSION

Among patients with acute hypoxemic respiratory failure, early extubation with high-flow nasal oxygen is a feasible and superior alternative to the conventional method of weaning, as it increases the number of invasive mechanical ventilation-free days.

Therapeutic novelties in acute heart failure and practical perspectives

Acute Heart Failure (AHF) is a leading cause of death and represents the most frequent cause of unplanned hospital admission in patients older than 65 years. Since the past decade, several randomized clinical trials have highlighted the importance and pivotal role of certain therapeutics, including decongestion by the combination of loop diuretics, the need for rapid goal-directed medical therapies implementation before discharge, risk stratification, and early follow-up after discharge therapies. Cardiogenic shock, defined as sustained hypotension with tissue hypoperfusion due to low cardiac output and congestion, is the most severe form of AHF and mainly occurs after acute myocardial infarction, which can progress to multiple organ failure. Although its prevalence is relatively low, cardiogenic shock complicates 12% of acute myocardial infarction. After a brief summary of the epidemiology of AHF and cardiogenic shock, followed by key pathophysiological points, we detailed current treatments in AHF and cardiogenic shock what every anaesthesiologist and intensivist needs to know, based on the latest guidelines and randomized clinical trials published in recent years.

High-flow nasal cannula oxygen therapy versus non-invasive ventilation in healthy respiratory physicians: a non-randomized study

Background

High-flow nasal cannula (HFNC) and non-invasive ventilation (NIV) are commonly used for respiratory support. This study aims to first establish whether to use HFNC or NIV based on comfort levels, and subsequently evaluate diaphragmatic function under equivalent comfort levels to determine the optimal modality for clinical application.

Methods

A self-controlled, non-randomized study was conducted with 10 healthy respiratory physicians as participants. Each subject was exposed to different HFNC settings, including flow rates of 20, 40, and 60 L/min at both 33 and 37°C. Additionally, participants were assessed under NIV mode. Comfort levels as the primary outcome were evaluated using the Visual Numerical Scale (VNS). Meanwhile, vital signs and diaphragmatic mobility were monitored through an electrocardiograph and ultrasound.

Results

HFNC at a flow rate of 20 L/min provided greater comfort than NIV. However, as the flow rate increased, this comfort benefit decreased. At 40 L/min, comfort levels were similar between HFNC and NIV, while at 60 L/min, HFNC was less comfortable than NIV. Notably, temperature variations between 33 and 37°C had no significant effect on comfort. In addition, under conditions of similar comfort, HFNC demonstrated slightly greater diaphragmatic mobility compared to NIV.

Conclusion

Our study indicated HFNC was the preferred choice for providing respiratory support at low to moderate flow rates in healthy volunteers not requiring respiratory support. By contrast, at higher flow rates, NIV discomfort was lower than HFNC discomfort.

Intravenous anesthesia with high-flow nasal cannula improves recovery in elderly undergoing ureteroscopic lithotripsy: a prospective controlled study

BACKGROUND

Intravenous anesthesia with high-flow nasal cannula (HFNC) has been reported to benefit oxygen reserves and enhance postoperative recovery in surgeries requiring low neuromuscular blockade. This study investigated whether HFNC improves recovery quality in elderly undergoing ureteroscopic holmium laser lithotripsy (UHLL).

METHODS

We enrolled 106 elderly patients undergoing UHLL, with 96 patients (48 per group) included in the final analysis. Patients were randomly assigned (1:1, stratified by sex) to receive either HFNC (HFNC group) or laryngeal mask airway (LMA) assisted general anesthesia (LMA group). The primary outcome was the Quality of Recovery 15-questionnaire (QoR-15) scores. Secondary outcomes included PACU stay duration, time to out-of-bed mobilization, length of hospital stay, airway dryness scores, surgeons' satisfaction, and postoperative complications.

RESULTS

Compared to the LMA group, the HFNC group achieved significantly higher QoR-15 scores (125.5 [118.3-130.0] vs. 136.5 [126.3-139.0]; difference = -9, 95%CI, -11 to -5; P < 0.001) on the first postoperative day. For secondary outcomes, the HFNC group had a shorter PACU stay (difference = 11.6 min, 95% CI, 10.4-12.8 min), earlier out-of-bed mobilization (difference = 31.8 min, 95% CI, 30.6-33.1 min), lower mouth (difference = 2, 95% CI, 1-3) and throat dryness scores (difference = 2, 95% CI, 1-3) at 30 min post-operation, and lower rates of postoperative sore throat (14.6% vs. 0%; P = 0.019) and cough with sputum (odds ratio [OR] = 9.4, 95% CI, 1.1-78.4). No significant differences were observed between the groups for other measures.

CONCLUSIONS

HFNC can improve recovery quality in elderly patients after UHLL compared to LMA-assisted general anesthesia.

TRIAL REGISTRATION

This trial was registered on July 20, 2023, in the Chinese Clinical Trial Registry (ChiCTR2300073757).

Best clinical model predicting extubation failure: a diagnostic accuracy post hoc analysis

PURPOSE

Predicting extubation failure remains a clinical challenge. This study aimed to determine diagnostic accuracy of models used at the bed side.

METHODS

Post hoc analysis of 2341 patients at all risk included in five multicenter randomized trials. Diagnostic accuracy of three clinical prediction models was compared: 3-factors model including age > 65y, chronic heart or pulmonary disease; 4-factors model adding prolonged mechanical ventilation; and 11-factors model including age > 65 years, ≥ 2 comorbidities, prolonged mechanical ventilation, acute heart failure as the primary indication for mechanical ventilation, moderate-to-severe chronic obstructive pulmonary disease, APACHE II score > 12 on extubation day, airway patency problems, inability to deal with respiratory secretions, not simple weaning, obesity, or hypercapnia at the end of the spontaneous breathing trial. Crude and adjusted for spontaneous breathing trial (SBT) models were compared for all-cause reintubation at 7 days using Youden and Kappa indexes.

RESULTS

The 3-factors model had a very low global prediction capability (Youden index 0.08 and Kappa index 0.04); the 4-factors and 11-factors models had low global prediction capability (Youden index 0.12 and 0.16, and Kappa index 0.06 and 0.07, respectively). Aggressive SBT strategies (pressure support ≥ 7 cm H2O with or without positive end-expiratory pressure) were associated with extubation failure risk (p < 0.001). All adjusted models had low diagnostic capability (0.08/0.03, 0.07/0.03, and 0.06/0.02 respectively).

CONCLUSION

Based on these results, the 3-factors model reported a very low diagnostic accuracy, and the 4 or 11-factors models showed similar low accuracy. No improvement was observed after adjusting for other aspects of weaning.

A Review of Prolonged Mechanical Ventilation in Pediatric Cardiac Surgery Patients: Risk Factors and Implications

Congenital heart disease (CHD) is a complex common defect in pediatric patients, and definitive treatment is usually cardiac surgery, especially for diseases with complex aetiology (ie, Critical CHD). While significant success has been reported due to improvement in diagnosis and treatment, the risk of mortality is still relatively higher than in the general population. Advances in surgical and post-surgical clinical management continue to increase survival in pediatric patients. However, mechanical ventilation (MV) during and after post-surgical procedures is linked with potential complications that may drive morbidity and mortality. Standard clinical practice dictates weaning patients off MV within the first 24 hours after surgery. However, various factors may increase the risk of extubation failure (EF), reintubation, and prolonged MV (PMV). Generally, PMV has been linked with increased length of pediatric intensive care unit (PICU) stay, morbidity, and higher risk of post-cardiac surgery mortality. The risk of PMV may be either preexisting (preoperative), perioperative/intraoperative, and/or postoperative, with the tendency to define the clinical course and patient outcomes. Monitoring and understanding the physiological dynamics of these risk factors may provide an opportunity for better and improved clinical management, which may translate into better patient outcomes. This review delves into the risk factors of extubation failure, reintubation, and PMV in pediatric cardiac surgery patients with complex (CHD) and the potential preventative measures to improve patients' outcomes.

Weaning of non COPD patients at high-risk of extubation failure assessed by lung ultrasound: the WIN IN WEAN multicentre randomised controlled trial

BACKGROUND

Postextubation respiratory failure (PRF) frequently complicates weaning from mechanical ventilation and may increase morbidity/mortality. Noninvasive ventilation (NIV) alternating with high-flow nasal oxygen (HFNO) may prevent PRF.

METHODS

Ventilated patients without chronic obstructive pulmonary disease (COPD) and at high-risk of PRF defined as a lung ultrasound score (LUS) ≥ 14 assessed during the spontaneous breathing trial, were included in a French-Chinese randomised controlled trial. PRF was defined by 2 among the following signs: SpO2 < 90%; Respiratory rate > 30 /min; hypercapnia; haemodynamic and/or neurological disturbances of respiratory origin. In the intervention group, prophylactic NIV alternating with HFNO was administered for 48 h following extubation. In the control group, conventional oxygen was used. Clinicians were informed on the LUS in the intervention group, those in the control group remained blind. The primary outcome was the incidence of PRF 48 h after extubation. Secondary outcomes were incidence of PRF and reintubation at day 7, number of ventilator-free days at day 28, length of ICU stay and mortality at day 28 and 90.

RESULTS

Two hundred and forty patients were randomised and 227 analysed (intervention group = 128 and control group = 99). PRF at H48 was reduced in the intervention group compared to the control group: relative risk 0.52 (0.31 to 0.88), p = 0.01. The benefit persisted at day 7: relative risk 0.62 (0.44 to 0.96), p = 0.02. Weaning failure imposing reconnection to mechanical ventilation was not reduced. In patients who developed PRF and were treated by rescue NIV, reintubation was avoided in 44% of control patients and in 12% of intervention patients (p = 0.008). Other secondary outcomes were not different between groups. From a resource utilisation standpoint, prophylactic NIV alternating with HFNO was more demanding and costly than conventional oxygen with rescue NIV to achieve same clinical outcome.

CONCLUSIONS

Compared to conventional oxygenation, prophylactic NIV alternating with HFNO significantly reduced postextubation respiratory failure but failed to reduce reintubation rate and mortality in patients without COPD at high risk of extubation failure. Prophylactic NIV alternating with HFNO was as efficient as recue NIV to treat postextubation respiratory failure.

Extubation Failure in the PICU: A Virtual Pediatric Systems Database Study, 2017-2021

OBJECTIVES

Extubation failure (EF) in PICU patients is reintubation within 48, 72, or 96 hours of planned extubation (EF48, EF72, and EF96, respectively). Standardized sedation protocols, extubation readiness testing, and noninvasive respiratory support are used to improve efficient liberation from mechanical ventilation (MV). We therefore aimed to review EF rates, time to failure, and the use of noninvasive respiratory support after extubation, 2017-2021.

DESIGN

Retrospective analysis of patients admitted to PICUs contributing to the Virtual Pediatric Systems (VPS, LLC) database, 2017-2021.

SETTING

One hundred thirty-six participating PICUs.

PATIENTS

All patients admitted to participating PICUs between January 1, 2017, and December 31, 2021, who had MV and met inclusion criteria for planned extubation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

There were 111,229 planned extubations with 5,143 reintubations within 48 hours. The EF48, EF72, and EF96 rates were 4.6%, 5.3%, and 5.8%, respectively. Higher rates of EF were associated with age younger than 6 months, underlying genetic conditions, medical comorbidities, or cardiac surgery. Failed extubation was also associated with higher Pediatric Risk of Mortality III scores, longer duration of MV, and longer PICU and hospital lengths of stay. From 2017 to 2021, there was an increase in the use of high-flow nasal cannula oxygen therapy after extubation from 16.6% to 20.2%.

CONCLUSIONS

In the VPS 2017-2021 dataset, we have found that the overall EF rates (EF48-EF96) have improved over this 5-year period. We are not able to assess the clinical benefit of this change, but it is evident that over the same period, there has been a concomitant increase in the use of postextubation noninvasive respiratory support. Further work is needed to look at the interaction of these effects in contemporary PICU practice.

Efficacy of high-flow nasal oxygen therapy in cancer patients with concurrent acute hypoxemic respiratory failure: a retrospective propensity score study

Acute respiratory failure is the leading cause of intensive care unit (ICU) admission of cancer patients. Studies of the efficacy of high-flow nasal cannula (HFNC) therapy were rarely conducted in cancer populations. We here compared the clinical effects of HFNC therapy and conventional oxygen therapy (COT) in cancer patients with concurrent acute hypoxemic respiratory failure (AHRF). In this single-center retrospective study, cancer patients with concurrent acute hypoxic respiratory failure either received initial oxygen therapy via HFNC (HFNC group, 68 patients) or received initial oxygen therapy via a nasal cannula, simple mask, or mask with reservoir bag (COT group, 133 patients). Groups were propensity score matched. Differences in respiratory rate (RR), heart rate (HR), and PaO2/FiO2 ratio before and after treatment in the two groups were compared using a mixed-effects model. The 28-day mortality risk was explored using a Cox proportional hazards model. The 24-h and 48-h PaO2/FIO2 ratios were significantly higher in the HFNC than in the COT group (210.5 mmHg vs. 178.5 mmHg; P < 0.01; 217.1 mm Hg vs. 181.6 mm Hg; P < 0.01, respectively). Differences in RR and HR between the groups at each time point were nonsignificant. The 28-day mortality rate was 17.4% vs. 38.1% for the HFNC and COT groups, respectively (P < 0.01). Hazard ratio was significantly higher for COT group (HR 2.6, 95% confidence interval 1.3, 5.3). Compared with COT, HFNC use for initial oxygen therapy can improve PaO2/FIO2 ratio and survival rate in cancer patients with AHRF.

Comments on "Post-extubation high-flow nasal cannula oxygen therapy versus non-invasive ventilation in chronic obstructive pulmonary disease with hypercapnic respiratory failure"

Dear Editor, The recent study published by Ketan et al. provides emerging evidence on the expanding indications for high-flow nasal oxygen therapy in chronic obstructive pulmonary disease. The indications for hypoxemic respiratory failure are robust, and the indications for HFNO in hypercapnic respiratory failure are emerging...

High-flow nasal cannula oxygen therapy versus noninvasive ventilation for elderly chronic obstructive pulmonary disease patients after extubation: a noninferior randomized controlled trial protocol

INTRODUCTION

Noninvasive ventilation (NIV) is widely used for sequential extubation in patients with chronic obstructive pulmonary disease (COPD). However, NIV may cause many adverse events such as claustrophobia, facial skin compression, air leakage, bloating, and even reflux aspiration, resulting in poor patient compliance/tolerance and high failure rate, especially for older adults who are at high risk of communication difficulties and consciousness disorder. High-flow nasal cannula (HFNC) oxygen therapy is a new alternative support to NIV, but whether it can effectively reduce the rate of re-intubation after extubation in elderly patients with COPD remains controversial. The purpose of this study is to explore the safety and efficacy of HFNC versus NIV for elderly COPD patients after extubation.

METHODS AND ANALYSIS

This study is an investigator-initiated, single-center, prospective, non-inferior, randomized controlled trial. Elderly patients (age > 65 years) who have received invasive ventilation and was diagnosed with COPD will be randomly assigned to HFNC group or NIV group immediately after extubation with a planned enrollment of 168 patients. The primary outcomes will be reintubation rates at 72 h and 7 days after extubation. Secondary outcomes will include treatment failure, post-extubation vital signs and arterial blood gases, the scores of compliance and comfort of patients, duration of respiratory support after extubation, respiratory support related adverse events, sleep quality scores, usage of sedative and analgesic drugs after extubation, and the incidence of delirium. Additionally, clinical outcomes such as ventilator-free days at 28 days post-randomization, tracheotomy rate, duration of intensive care unit (ICU) and hospital stay, ICU and hospital mortality will be evaluated.

ETHICS AND DISSEMINATION

This study has been approved by the Ethics Committee of West China Hospital of Sichuan University (2023-2284). Informed consent is required. It is expected that a follow-up randomized controlled trial will be conducted. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences.

TRIAL REGISTRATION

The study was retrospectively registered at ClinicalTrials.gov (ChiCTR2400087312).

Liberation from Mechanical Ventilation in Critically Ill Patients: Korean Society of Critical Care Medicine Clinical Practice Guidelines

BACKGROUND

Successful liberation from mechanical ventilation is one of the most crucial processes in critical care, because it is the first step through which a respiratory failure patient begins to transition out of the intensive care unit, and return to normal life. Therefore, when devising appropriate strategies for removing mechanical ventilation, it is essential to consider scientific and systematic approaches, as well as the individual experiences of healthcare professionals. Recently, numerous studies have investigated methods and tools to identify when mechanically ventilated patients are ready to breathe on their own. The Korean Society of Critical Care Medicine therefore provides these recommendations to clinicians for liberation from the ventilator.

METHODS

Meta-analyses and comprehensive syntheses were used to thoroughly review, compile, and summarize the complete body of relevant evidence. All studies were meticulously assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) method, and the outcomes were presented succinctly as evidence profiles. These evidence syntheses were discussed by a multidisciplinary committee of experts in mechanical ventilation, who then developed and approved the recommendations.

RESULTS

Recommendations for nine questions on ventilator liberation about Population, Intervention, Comparator, and Outcome (PICO) are presented in this document. This guideline presents seven conditional recommendations, one expert consensus recommendation, and one conditional deferred recommendation.

CONCLUSION

We developed these clinical guidelines for mechanical ventilation liberation to provide meaningful recommendations. These guidelines reflect the best treatment for patients seeking liberation from mechanical ventilation.

The effect of mechanical ventilation compared to high-flow nasal cannula on gastric residual volume and reflux events using novel automated technology

BACKGROUND & AIM

High flow nasal cannula (HFNC) oxygen therapy is frequently used following extubation. A case report, utilizing an innovative medical technology (The smART + Platform, ART MEDICAL Ltd., Netanya, Israel) that enables the detection of gastric refluxes and gastric residual volumes (GRV), has suggested that HFNC may be associated with increased reflux events and GRV. This study measured reflux events and GRV using smART+ in mechanically ventilated patients before and after extubation while they were receiving HFNC therapy. We aim to show if there is a significant difference in reflux events and GRV between HFNC users and mechanically ventilated patients.

METHODS

This is a post hoc analysis examines data of a randomized controlled trial (RCT) involving critically ill adult patients who received enteral nutrition through the smART + Platform. The study was approved by the local ethics committee. We compared the frequency and amplitude of reflux events and GRV in mechanically ventilated patients. These parameters were assessed both 3 h before extubation and subsequently after extubation when the patients were connected to HFNC. Patients served as their own controls. To evaluate the differences between the pre- and post-extubation measurements, we applied a parametric paired t-test.

RESULTS

Ten patients (mean age of 58 years; mean APACHE II score 22; mean 3.9 days of mechanical ventilation) were included. Three hours prior extubation the mean GRV was 4.1 ml/h compared to 14.03 ml/h on HFNC (p = 0.004). The mean frequency of major reflux events was 2.33/h in ventilated patients versus 4.4/h in the HFNC patients (p = 0.73). The mean frequency of major reflux events was 9.17/h in ventilated patients versus 9.83/h in HFNC patients (p = 0.14).

CONCLUSIONS

Leveraging the smART + Platform, we demonstrated that the use of HFNC significantly increases GRV compared with patients on mechanical ventilation and may increase the frequency of major reflux events, thereby increasing the risk of aspiration. Further studies are required to support our conclusions.

Prolonged weaning from mechanical ventilation: who, what, when and how?

Weaning from invasive mechanical ventilation is an important part of the management of respiratory failure patients. Patients can be classified into those who wean on the first attempt (simple weaning), those who require up to three attempts (difficult weaning) and those who require more than three attempts (prolonged weaning). The process of weaning includes adequately treating the underlying cause of respiratory failure, assessing the readiness to wean, evaluating the response to a reduction in ventilatory support, and eventually liberation from mechanical ventilation and extubation or decannulation. Post-extubation respiratory failure is a contributor to poorer outcomes. Identifying and addressing modifiable risk factors for post-extubation respiratory failure is important; noninvasive ventilation and high-flow nasal cannulae may be useful bridging aids after extubation. Factors to consider in the pathophysiology of prolonged mechanical ventilation include increased respiratory muscle load, reduced respiratory muscle capacity and reduced respiratory drive. Management of these patients involves a multidisciplinary team, to first identify the cause of failed weaning attempts, and subsequently optimise the patient's physiology to improve the likelihood of being successfully weaned from invasive mechanical ventilation.

Effect of prophylactic noninvasive oxygen therapy after planned extubation on extubation failure in high-risk patients: a retrospective propensity score-matched cohort study

Background

Extubation failure (EF) is common in the intensive care unit (ICU) and is associated with poor prognosis, especially in high-risk patients. However, the efficacy of prophylactic noninvasive oxygen therapy (NIT), including noninvasive ventilation (NIV) and high-flow nasal cannula (HFNC), in reducing EF in high-risk patients remains controversial. Therefore, we aimed to evaluate the effect of post-extubation prophylactic NIT on EF in high-risk patients.

Methods

This was a retrospective observational study conducted in the ICU from March 2018 to December 2023. We included adult patients at high risk for reintubation who were mechanically ventilated for over 24 h and successfully passed the spontaneous breathing trial (SBT). Immediately after extubation, patients underwent NIT or conventional oxygenation therapy (COT). The primary outcome was the EF rate within 7 days after extubation.

Results

There were 440 patients in the NIT group and 274 in the COT group. After propensity-score matching, 227 subjects were enrolled in each group. NIT reduced the rate of EF (18.0% vs. 34.3%, p < 0.001) and reintubation (10.5% vs. 18.2% p = 0.003) compared with COT, which was confirmed in propensity-matched cohort (17.6% vs. 32.2%, p < 0.001; 11.5% vs. 19.8%, p = 0.014). Multivariate logistic regression analysis indicated that prophylactic NIT (p = 0.001) and higher ROX index (p = 0.022) were associated with reduced risk of EF. While higher fluid balance (p = 0.013), higher RSBI (p < 0.001), and the occurrence of delirium (p = 0.032) may be the risk factors for EF. Subgroup analysis showed that post-extubation NIT was more effective in elderly patients, and HFNC was non-inferior to NIV in reducing EF. While HFNC had a tendency to reduce the incidence of delirium.

Conclusion

Post-extubation prophylactic NIT is effective in reducing EF in high-risk patients, especially in the elderly patients. HFNC is an alternative treatment to NIV. Fluid balance, RSBI, ROX index, and delirium are associated with the occurrence of EF.

Position Statement of ISCCM Committee on Weaning from Mechanical Ventilator

Background and purpose

Weaning from a mechanical ventilator is a milestone in the recovery of seriously ill patients in Intensive care. Failure to wean and re-intubation adversely affects the outcome. The method of mechanical ventilation (MV) varies between different ICUs and so does the practice of weaning. Therefore, updated guidelines based on contemporary literature are designed to guide intensivists in modern ICUs. This is the first ISCCM Consensus Statement on weaning complied by a committee on weaning. The recommendations are intended to be used by all the members of the ICU (Intensivists, Registrars, Nurses, and Respiratory Therapists).

Methods

A Committee on weaning from MV, formed by the Indian Society of Critical Care Medicine (ISCCM) has formulated this statement on weaning from mechanical ventilators in intensive care units (ICUs) after a review of the literature. Literature was first circulated among expert committee members and allotted sections to each member. Sections of the statement written by sectional authors were peer-reviewed on multiple occasions through virtual meetings. After the final manuscript is accepted by all the committee members, it is submitted for peer review by central guideline committee of ISCCM. Once approved it has passed through review by the Editorial Board of IJCCM before it is published here as "ISCCM consensus statement on weaning from mechanical ventilator". As per the standard accepted for all its guidelines of ISCCM, we followed the modified grading of recommendations assessment, development and evaluation (GRADE) system to classify the quality of evidence and strength of recommendation. Cost-benefit, risk-benefit analysis, and feasibility of implementation in Indian ICUs are considered by the committee along with the strength of evidence. Type of ventilators and their modes, ICU staffing pattern, availability of critical care nurses, Respiratory therapists, and day vs night time staffing are aspects considered while recommending for or against any aspect of weaning.

Result

This document makes recommendation on various aspects of weaning, namely, definition, timing, weaning criteria, method of weaning, diagnosis of failure to wean, defining difficult to wean, Use of NIV, HFOV as adjunct to weaning, role of tracheostomy in weaning, weaning in of long term ventilated patients, role of physiotherapy, mobilization in weaning, Role of nutrition in weaning, role of diaphragmatic ultrasound in weaning prediction etc. Out of 42 questions addressed; the committee provided 39 recommendations and refrained from 3 questions. Of these 39; 32 are based on evidence and 7 are based on expert opinion of the committee members. It provides 27 strong recommendations and 12 weak recommendations (suggestions).

Conclusion

This guideline gives extensive review on weaning from mechanical ventilator and provides various recommendations on weaning from mechanical ventilator. Though all efforts are made to make is as updated as possible one needs to review any guideline periodically to keep it in line with upcoming concepts and standards.

How to cite this article

Clerk AM, Shah RJ, Kothari J, Sodhi K, Vadi S, Bhattacharya PK, et al. Position Statement of ISCCM Committee on Weaning from Mechanical Ventilator. Indian J Crit Care Med 2024;28(S2):S233-S248.

Bridging the critically ill patient with acute to chronic liver failure to liver transplantation

Liver transplantation (LT) has emerged as an effective therapy for severe forms of acute-on-chronic liver failure (ACLF), an entity characterized by the development of multiorgan failure and high short-term mortality. The aim of critical care management of ACLF patients is to rapidly treat precipitating events and aggressively support failing organs to ensure that patients may successfully undergo LT or, less frequently, recover. Malnutrition and sarcopenia are frequently present, adversely impacting the prognosis of these patients. Management of critical care patients with ACLF is complex and requires the participation of different specialties. Once the patient is stabilized, a rapid evaluation for salvage LT should be performed because the time window for LT is often narrow. The development of sepsis and prolonged organ support may preclude LT or diminish its chances of success. The current review describes strategies to bridge severe ACLF patients to LT, highlights the minimal evaluation required for listing and the currently suggested contraindications to proceed with LT, and addresses different aspects of management during the perioperative and early posttransplant period.

Noninvasive ventilation on reintubation in patients with obesity and hypoxemic respiratory failure following abdominal surgery: a post hoc analysis of a randomized clinical trial

PURPOSE

Although noninvasive ventilation (NIV) may reduce reintubation in patients with acute hypoxemic respiratory failure following abdominal surgery, this strategy has not been specifically assessed in patients with obesity.

METHODS

We conducted a post hoc analysis of a multicenter randomized controlled trial comparing NIV delivered via facial mask to standard oxygen therapy among patients with obesity and acute hypoxemic respiratory failure within 7 days after abdominal surgery. The primary outcome was reintubation within 7 days. Secondary outcomes were invasive ventilation-free days at day 30, intensive care unit (ICU)-acquired pneumonia and 30-day survival.

RESULTS

Among 293 patients with hypoxemic respiratory failure following abdominal surgery, 76 (26%) patients had obesity and were included in the intention-to-treat analysis. Reintubation rate was significantly lower with NIV (13/42, 31%) than with standard oxygen therapy (19/34, 56%) within 7 days (absolute difference: - 25%, 95% confidence interval (CI) - 49 to - 1%, p = 0.03). NIV was associated with significantly more invasive ventilation-free days compared with standard oxygen therapy (27.1 ± 8.6 vs 22.7 ± 11.1 days; p = 0.02), while fewer patients developed ICU-acquired pneumonia (1/42, 2% vs 6/34, 18%; p = 0.04). The 30-day survival was 98% in the NIV group (41/42) versus 85% in the standard oxygen therapy (p = 0.08). In patients with body mass index (BMI) < 30 kg/m2, no significant difference was observed between NIV (36/105, 34%) and standard oxygen therapy (47/109, 43%, p = 0.03). An interaction test showed no statistically significant difference between the two subsets (BMI ≥ 30 kg/m2 and BMI < 30 kg/m2).

CONCLUSIONS

Among patients with obesity and hypoxemic respiratory failure following abdominal surgery, use of NIV compared with standard oxygen therapy reduced the risk of reintubation within 7 days, contrary to patients without obesity. However, no interaction was found according to the presence of obesity or not, suggesting either a lack of power to conclude in the non-obese subgroup despite existing differences, or that the statistical difference found in the overall sample was driven by a large effect in the obese subsets.

High flow nasal cannula oxygen therapy versus non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease with acute-moderate hypercapnic respiratory failure: a randomized controlled non-inferiority trial

BACKGROUND

Although cumulative studies have demonstrated a beneficial effect of high-flow nasal cannula oxygen (HFNC) in acute hypercapnic respiratory failure, randomized trials to compare HFNC with non-invasive ventilation (NIV) as initial treatment in acute exacerbations of chronic obstructive pulmonary disease (AECOPD) patients with acute-moderate hypercapnic respiratory failure are limited. The aim of this randomized, open label, non-inferiority trial was to compare treatment failure rates between HFNC and NIV in such patients.

METHODS

Patients diagnosed with AECOPD with a baseline arterial blood gas pH between 7.25 and 7.35 and PaCO2 ≥ 50 mmHg admitted to two intensive care units (ICUs) at a large tertiary academic teaching hospital between March 2018 and December 2022 were randomly assigned to HFNC or NIV. The primary endpoint was the rate of treatment failure, defined as endotracheal intubation or a switch to the other study treatment modality. Secondary endpoints were rates of intubation or treatment change, blood gas values, vital signs at one, 12, and 48 h, 28-day mortality, as well as ICU and hospital lengths of stay.

RESULTS

225 total patients (113 in the HFNC group and 112 in the NIV group) were included in the intention-to-treat analysis. The failure rate of the HFNC group was 25.7%, while the NIV group was 14.3%. The failure rate risk difference between the two groups was 11.38% (95% CI 0.25-21.20, P = 0.033), which was higher than the non-inferiority cut-off of 9%. In the per-protocol analysis, treatment failure occurred in 28 of 110 patients (25.5%) in the HFNC group and 15 of 109 patients (13.8%) in the NIV group (risk difference, 11.69%; 95% CI 0.48-22.60). The intubation rate in the HFNC group was higher than in the NIV group (14.2% vs 5.4%, P = 0.026). The treatment switch rate, ICU and hospital length of stay or 28-day mortality in the HFNC group were not statistically different from the NIV group (all P > 0.05).

CONCLUSION

HFNC was not shown to be non-inferior to NIV and resulted in a higher incidence of treatment failure than NIV when used as the initial respiratory support for AECOPD patients with acute-moderate hypercapnic respiratory failure.

TRIAL REGISTRATION

chictr.org (ChiCTR1800014553). Registered 21 January 2018, http://www.chictr.org.cn.

Effect of lung volume preservation during spontaneous breathing trial on successful extubation in patients receiving mechanical ventilation: protocol for a multicenter clinical trial

BACKGROUND

In standard weaning from mechanical ventilation, a successful spontaneous breathing test (SBT) consisting of 30 min 8 cmH2O pressure-support ventilation (PSV8) without positive end-expiratory pressure (PEEP) is followed by extubation with continuous suctioning; however, these practices might promote derecruitment. Evidence supports the feasibility and safety of extubation without suctioning. Ultrasound can assess lung aeration and respiratory muscles. We hypothesize that weaning aiming to preserve lung volume can yield higher rates of successful extubation.

METHODS

This multicenter superiority trial will randomly assign eligible patients to receive either standard weaning [SBT: 30-min PSV8 without PEEP followed by extubation with continuous suctioning] or lung-volume-preservation weaning [SBT: 30-min PSV8 + 5 cmH2O PEEP followed by extubation with positive pressure without suctioning]. We will compare the rates of successful extubation and reintubation, ICU and hospital stays, and ultrasound measurements of the volume of aerated lung (modified lung ultrasound score), diaphragm and intercostal muscle thickness, and thickening fraction before and after successful or failed SBT. Patients will be followed for 90 days after randomization.

DISCUSSION

We aim to recruit a large sample of representative patients (N = 1600). Our study cannot elucidate the specific effects of PEEP during SBT and of positive pressure during extubation; the results will show the joint effects derived from the synergy of these two factors. Although universal ultrasound monitoring of lungs, diaphragm, and intercostal muscles throughout weaning is unfeasible, if derecruitment is a major cause of weaning failure, ultrasound may help clinicians decide about extubation in high-risk and borderline patients.

TRIAL REGISTRATION

The Research Ethics Committee (CEIm) of the Fundació Unió Catalana d'Hospitals approved the study (CEI 22/67 and 23/26). Registered at ClinicalTrials.gov in August 2023. Identifier: NCT05526053.

Two-year survival after scheduled extubation in patients with pneumonia or ARDS: a prospective observational study

PURPOSE

To report two-year survival after scheduled extubation in patients with pneumonia or acute respiratory distress syndrome (ARDS).

METHODS

This was a prospective observational study performed in a respiratory ICU of a teaching hospital. Pneumonia or ARDS patients who successfully completed a spontaneous breathing trial were enrolled. Data were collected before extubation. Patients were followed up to two years by phone every 3 months.

RESULTS

A total of 230 patients were enrolled in final analysis. One-, 3-, 6-, 12-, and 24-month survival was 77.4%, 63.8%, 61.3%, 57.8%, and 47.8%, respectively. Cox regression shows that Charlson comorbidity index (hazard ratio: 1.20, 95% confidence interval: 1.10-1.32), APACHE II score before extubation (1.11, 1.05-1.17), cough peak flow before extubation (0.993, 0.986-0.999), and extubation failure (3.96, 2.51-6.24) were associated with two-year mortality. To predict death within two years, the area under the curve of receiver operating characteristic was 0.79 tested by Charlson comorbidity index, 0.75 tested by APACHE II score, and 0.75 tested by cough peak flow. Two-year survival was 31% and 77% in patients with Charlson comorbidity index ≥ 1 and < 1, 28% and 62% in patients with APACHE II score ≥ 12 and < 12, and 64% and 17% in patients with cough peak flow > 58 and ≤ 58 L/min, respectively.

CONCLUSIONS

Comorbidity, disease severity, weak cough and extubation failure were associated with increased two-year mortality in pneumonia or ARDS patients who experienced scheduled extubation. It provides objective information to caregivers to improve decision-making process during hospitalization and post discharge.

[Non-invasive Mechanical Ventilation in Acute Respiratory Failure. Clinical Practice Guidelines - on behalf of the German Society of Pneumology and Ventilatory Medicine]

The guideline update outlines the advantages as well as the limitations of NIV in the treatment of acute respiratory failure in daily clinical practice and in different indications.Non-invasive ventilation (NIV) has a high value in therapy of hypercapnic acute respiratory failure, as it significantly reduces the length of ICU stay and hospitalization as well as mortality.Patients with cardiopulmonary edema and acute respiratory failure should be treated with continuous positive airway pressure (CPAP) and oxygen in addition to necessary cardiological interventions. This should be done already prehospital and in the emergency department.In case of other forms of acute hypoxaemic respiratory failure with only mild or moderately disturbed gas exchange (PaO2/FiO2 > 150 mmHg) there is no significant advantage or disadvantage compared to high flow nasal oxygen (HFNO). In severe forms of ARDS NIV is associated with high rates of treatment failure and mortality, especially in cases with NIV-failure and delayed intubation.NIV should be used for preoxygenation before intubation. In patients at risk, NIV is recommended to reduce extubation failure. In the weaning process from invasive ventilation NIV essentially reduces the risk of reintubation in hypercapnic patients. NIV is regarded useful within palliative care for reduction of dyspnea and improving quality of life, but here in concurrence to HFNO, which is regarded as more comfortable. Meanwhile NIV is also recommended in prehospital setting, especially in hypercapnic respiratory failure and pulmonary edema.With appropriate monitoring in an intensive care unit NIV can also be successfully applied in pediatric patients with acute respiratory insufficiency.

ChatGPT achieves comparable accuracy to specialist physicians in predicting the efficacy of high-flow oxygen therapy

Background

The failure of high-flow nasal cannula (HFNC) oxygen therapy can necessitate endotracheal intubation in patients, making timely prediction of the intubation risk following HFNC therapy crucial for reducing mortality due to delays in intubation.

Objectives

To investigate the accuracy of ChatGPT in predicting the endotracheal intubation risk within 48 h following HFNC therapy and compare it with the predictive accuracy of specialist and non-specialist physicians.

Methods

We conducted a prospective multicenter cohort study based on the data of 71 adult patients who received HFNC therapy. For each patient, their baseline data and physiological parameters after 6-h HFNC therapy were recorded to create a 6-alternative-forced-choice questionnaire that asked participants to predict the 48-h endotracheal intubation risk using scale options ranging from 1 to 6, with higher scores indicating a greater risk. GPT-3.5, GPT-4.0, respiratory and critical care specialist physicians and non-specialist physicians completed the same questionnaires (N = 71) respectively. We then determined the optimal diagnostic cutoff point, using the Youden index, for each predictor and 6-h ROX index, and compared their predictive performance using receiver operating characteristic (ROC) analysis.

Results

The optimal diagnostic cutoff points were determined to be ≥ 4 for both GPT-4.0 and specialist physicians. GPT-4.0 demonstrated a precision of 76.1 %, with a specificity of 78.6 % (95%CI = 52.4-92.4 %) and sensitivity of 75.4 % (95%CI = 62.9-84.8 %). In comparison, the precision of specialist physicians was 80.3 %, with a specificity of 71.4 % (95%CI = 45.4-88.3 %) and sensitivity of 82.5 % (95%CI = 70.6-90.2 %). For GPT-3.5 and non-specialist physicians, the optimal diagnostic cutoff points were ≥5, with precisions of 73.2 % and 64.8 %, respectively. The area under the curve (AUC) in ROC analysis for GPT-4.0 was 0.821 (95%CI = 0.698-0.943), which was the highest among the predictors and significantly higher than that of non-specialist physicians [0.662 (95%CI = 0.518-0.805), P = 0.011].

Conclusion

GPT-4.0 achieves an accuracy level comparable to specialist physicians in predicting the 48-h endotracheal intubation risk following HFNC therapy, based on patient baseline data and physiological parameters after 6-h HFNC therapy.

Basing intubation of acutely hypoxemic patients on physiologic principles

The decision to intubate a patient with acute hypoxemic respiratory failure who is not in apparent respiratory distress is one of the most difficult clinical decisions faced by intensivists. A conservative approach exposes patients to the dangers of hypoxemia, while a liberal approach exposes them to the dangers of inserting an endotracheal tube and invasive mechanical ventilation. To assist intensivists in this decision, investigators have used various thresholds of peripheral or arterial oxygen saturation, partial pressure of oxygen, partial pressure of oxygen-to-fraction of inspired oxygen ratio, and arterial oxygen content. In this review we will discuss how each of these oxygenation indices provides inaccurate information about the volume of oxygen transported in the arterial blood (convective oxygen delivery) or the pressure gradient driving oxygen from the capillaries to the cells (diffusive oxygen delivery). The decision to intubate hypoxemic patients is further complicated by our nescience of the critical point below which global and cerebral oxygen supply become delivery-dependent in the individual patient. Accordingly, intubation requires a nuanced understanding of oxygenation indexes. In this review, we will also discuss our approach to intubation based on clinical observations and physiologic principles. Specifically, we consider intubation when hypoxemic patients, who are neither in apparent respiratory distress nor in shock, become cognitively impaired suggesting emergent cerebral hypoxia. When deciding to intubate, we also consider additional factors including estimates of cardiac function, peripheral perfusion, arterial oxygen content and its determinants. It is not possible, however, to pick an oxygenation breakpoint below which the benefits of mechanical ventilation decidedly outweigh its hazards. It is futile to imagine that decision making about instituting mechanical ventilation in an individual patient can be condensed into an algorithm with absolute numbers at each nodal point. In sum, an algorithm cannot replace the presence of a physician well skilled in the art of clinical evaluation who has a deep understanding of pathophysiologic principles.

Role of Prolonged Intubation in Vocal Fold Motion Impairment in Critically Ill Patients

OBJECTIVE

COVID-19 upsurge in orotracheal intubation (OTI) has opened a new opportunity for studying associated complications. Vocal fold motion impairment (VFMI) is a known complication of OTI. The present study sought to determine the impact of OTI and prolonged OTI on the risk of developing VFMI; to identify both risk and protective factors associated with it.

STUDY DESIGN

Retrospective cohort study.

SETTING

Multicenter.

METHODS

Medical charts were reviewed for all patients that received invasive mechanical ventilation with a subsequent flexible laryngoscopic assessment between March 2020 and March 2022. The main outcomes were the presence of VFMI, including immobility (VFI) and hypomobility (VFH).

RESULTS

A total of 155 patients were included, 119 (76.8%) COVID-19 and 36 (23.2%) non-COVID-19 patients; overall 82 (52.9%) were diagnosed with VFMI. Eighty (52.3%) patients underwent a tracheostomy. The median (IQR) intubation duration was 18 (11-24.25) days, while the median (IQR) time to tracheostomy was 22 (16-29). In the adjusted model, we observed there was a 68% increased risk for VFMI from day 21 of intubation (RR: 1.68; 95% CI 1.07-2.65; P = 0.025).

CONCLUSIONS

VFMI is a frequent complication in severely ill patients that undergo intubation. A prolonged OTI was associated with an increased risk of VFMI, highlighting the importance of timely tracheostomy. Further research is needed to confirm these findings in other subsets of critically ill patients.

Perioperative Management in Neuromuscular Diseases: A Narrative Review

Patients with neuromuscular diseases are particularly vulnerable in the perioperative period to the development of pulmonary and cardiac complications, or medication side effects. These risks could include hypoventilation, aspiration pneumonia, exacerbation of underlying cardiomyopathy, arrhythmias, adrenal insufficiency, prolonged neuromuscular blockade, issues related to thermoregulation, rhabdomyolysis, malignant hyperthermia, or prolonged mechanical ventilation. Interventions at each of the perioperative stages can be implemented to mitigate these risks. A careful pre-operative evaluation may help identify risk factors so that appropriate interventions are initiated, including cardiology consultation, pulmonary function tests, initiation of noninvasive ventilation, or implementation of preventive measures. Important intraoperative issues include positioning, airway and anesthetic management, and adequate ventilation. The postoperative period may require correction of electrolyte abnormalities, control of secretions with medications, manual or mechanical cough assistance, avoiding the risk of reintubation, judicious pain control, and appropriate medication management. The aim of this review is to increase awareness of the particular surgical challenges in this vulnerable population, and guide the clinician on the various evaluations and interventions that may result in a favorable surgical outcome.

Multidisciplinary Consensus on the Management of Non-Invasive Respiratory Support in the COVID-19 Patient

Acute respiratory failure due to COVID-19 pneumonia often requires a comprehensive approach that includes non-pharmacological strategies such as non-invasive support (including positive pressure modes, high flow therapy or awake proning) in addition to oxygen therapy, with the primary goal of avoiding endotracheal intubation. Clinical issues such as determining the optimal time to initiate non-invasive support, choosing the most appropriate modality (based not only on the acute clinical picture but also on comorbidities), establishing criteria for recognition of treatment failure and strategies to follow in this setting (including palliative care), or implementing de-escalation procedures when improvement occurs are of paramount importance in the ongoing management of severe COVID-19 cases. Organizational issues, such as the most appropriate setting for management and monitoring of the severe COVID-19 patient or protective measures to prevent virus spread to healthcare workers in the presence of aerosol-generating procedures, should also be considered. While many early clinical guidelines during the pandemic were based on previous experience with acute respiratory distress syndrome, the landscape has evolved since then. Today, we have a wealth of high-quality studies that support evidence-based recommendations to address these complex issues. This document, the result of a collaborative effort between four leading scientific societies (SEDAR, SEMES, SEMICYUC, SEPAR), draws on the experience of 25 experts in the field to synthesize knowledge to address pertinent clinical questions and refine the approach to patient care in the face of the challenges posed by severe COVID-19 infection.

Noninvasive Ventilation in the Cardiac Intensive Care Unit

Over the last several decades, the cardiac intensive care unit (CICU) has seen an increase in the complexity of the patient population and etiologies requiring CICU admission. Currently, respiratory failure is the most common reason for admission to the contemporary CICU. As a result, noninvasive ventilation (NIV), including noninvasive positive-pressure ventilation and high-flow nasal cannula, has been increasingly utilized in the management of patients admitted to the CICU. In this review, we detail the different NIV modalities and summarize the evidence supporting their use in conditions frequently encountered in the CICU. We describe the unique pathophysiologic interactions between positive pressure ventilation and left and/or right ventricular dysfunction. Additionally, we discuss the evidence and strategies for utilization of NIV as a method to reduce extubation failure in patients who required invasive mechanical ventilation. Lastly, we examine unique considerations for managing respiratory failure in certain, high-risk patient populations such as those with right ventricular failure, severe valvular disease, and adult congenital heart disease. Overall, it is critical for clinicians who practice in the CICU to be experts with the application, risks, benefits, and modalities of NIV in cardiac patients with respiratory failure.

High-Flow Nasal Cannula Oxygen Therapy versus Non-Invasive Ventilation in patients at very high risk for extubating failure: A systematic review of randomized controlled trials

BACKGROUND

Mechanical ventilation is commonly used for managing respiratory failure in chronic obstructive pulmonary disease (COPD) patients, but weaning patients off ventilator support can be challenging and associated with complications. While many patients respond well to Non-invasive ventilation (NIV), a significant proportion may not respond as favourably. We aimed to assess whether high-flow nasal cannula (HFNC) is equally effective as NIV in reducing extubation failure among previously intubated COPD patients.

METHODS

This systematic review was carried out in line with PRISMA guidelines We searched PubMed, Scopus, Web of Science, and Cochrane library from inception until February 15, 2023. Randomized Clinical Trials (RCTs) of adults at high risk for extubating failure were included. We examined the use of HFNC as the intervention and NIV as the comparator. Our outcome of interest included, reintubation rate, length of hospital or intensive care unit (ICU) stay, adverse events, and time to reintubation. The Cochrane risk-of-bias tool was used for randomized trials to assess risk of bias.

RESULTS

We identified 348 citations, 11 of which were included, representing 2,666 patients. The trials indicate that HFNC is comparable to NIV in preventing reintubation after extubating in COPD patients. In comparison to NIV, HFNC also produced improved tolerance, comfort, and less complications such as airway care interventions. NIV with active humification may be more effective that HFNC in avoiding reintubation in patients who are at extremely high risk for extubating failure.

CONCLUSION

The inconclusive nature of emerging evidence highlights the need for additional studies to establish the efficacy and suitability of HFNC as an alternative to NIV for previously intubated COPD patients. Clinicians should consider the available options and individualize their approach based on patient characteristics. Future research should focus on addressing these gaps in knowledge to guide clinical decision-making and optimize outcomes for this patient population.

Ventilator Weaning and Extubation

Increasing evidence supports specific approaches to liberate patients from invasive ventilation including the use of liberation protocols, inspiratory assistance during spontaneous breathing trials (SBTs), early extubation of patients with chronic obstructive pulmonary disease to noninvasive ventilation, and prophylactic use of noninvasive support strategies after extubation. Additional research is needed to elucidate the best criteria to identify patients who are ready to undergo an SBT and to inform optimal screening frequency, the best SBT technique and duration, extubation assessments, and extubation decision-making. Additional clarity is also needed regarding the optimal timing to measure and report extubation success.

Intraoperative Use of High-Flow Nasal Cannula in Elderly Patients Undergoing Hip Fracture Repair Under Spinal Anesthesia: A Randomized Controlled Study

BACKGROUND

The procedure of hip fracture repair poses a risk for postoperative pulmonary complications (PPCs) in elderly patients, accompanied by anesthesia and operations. Various noninvasive methods of respiratory support are used as prophylactic and therapeutic, mainly in the postoperative period.  Objective: This study aims to determine whether intraoperative use of a high-flow nasal cannula (HFNC) impacts elderly patient outcomes after hip fracture surgery.

METHOD

Seventy patients aged 65 and older undergoing traumatic hip surgery under spinal anesthesia for isolated hip fractures were randomly assigned to either an interventional group (I) utilizing a high-flow nasal cannula or a control group (C) without respiratory intervention in a six-month single-blind controlled study at Sahloul Teaching Hospital.

RESULTS

The two groups had identical socio-demographic traits and baseline data. Respiratory postoperative complications occurred in two patients in group (I) and in nine patients in group (C), with a significant difference (p = 0.023). The main respiratory postoperative complications in group (I) were atelectasis (one case) and pulmonary edema (one case). The main respiratory postoperative complications in group (C) were atelectasis (four cases), pneumonia (two cases), COPD decompensation (two cases), and pulmonary edema (one case). No intensive care unit admissions or intraoperative complications were associated with using HFNC. The mean length of stay (LOS) in the hospital was 8.83 ± 2.91 for group I and 10.46 ± 3.4 for group (C), which differed significantly (p = 0.03) with no in-hospital mortality for the two groups.

CONCLUSION

The intraoperative administration of HFNC may lower the incidence of postoperative respiratory complications and the duration of hospital stays.

Effectiveness of high flow nasal cannula (HFNC) versus bilevel positive airway pressure (BiPAP) in preventing tracheal reintubation in patients with high risk of extubation failure in intensive care unit - A randomised comparative trial

Background and Aims

The incidence of tracheal extubation failure in high-risk patients is higher, and non-invasive ventilation is suggested to avoid tracheal reintubation. This study compares the effectiveness of bilevel positive airway pressure (BiPAP) and high flow nasal cannula (HFNC) to reduce the rate of reintubation in intensive care unit (ICU) patients with increased risk of extubation failure.

Methods

This randomised comparative trial was conducted on 60 high-risk patients on mechanical ventilators admitted to the ICU, ready for weaning after a spontaneous breathing trial. They were randomised to Group H for HFNC and Group B for BiPAP therapy. Designated therapy was administered in these high-risk patients for up to 48 hours after tracheal extubation. Haemodynamic parameters [mean arterial pressure (MAP), heart rate (HR), respiratory rate (RR), a saturation of peripheral oxygen (SpO2), electrocardiogram (ECG)], arterial blood gas analysis (ABG) parameter [potential of hydrogen (pH), partial pressure of carbon dioxide (pCO2), partial pressure of oxygen/fraction of inspired oxygen (paO2/FiO2) ratio], the effectiveness of cough, comfort level was recorded and continuous monitoring for signs of respiratory distress and failure was done.

Results

Most of the patients were obese and had more than two risk factors for extubation failure. Several patients in Group B have significantly higher successful extubation than in Group H (P = 0.044). Most of the reintubation took place within 24 hours. The HFNC therapy was more comfortable and acceptable to patients.

Conclusion

BiPAP therapy was more efficient than HFNC in preventing tracheal reintubation among patients with a high risk of extubation failure.

Liberation from mechanical ventilation in critically ill patients: Korean Society of Critical Care Medicine Clinical Practice Guidelines

BACKGROUND

Successful liberation from mechanical ventilation is one of the most crucial processes in critical care because it is the first step by which a respiratory failure patient begins to transition out of the intensive care unit and return to their own life. Therefore, when devising appropriate strategies for removing mechanical ventilation, it is essential to consider not only the individual experiences of healthcare professionals, but also scientific and systematic approaches. Recently, numerous studies have investigated methods and tools for identifying when mechanically ventilated patients are ready to breathe on their own. The Korean Society of Critical Care Medicine therefore provides these recommendations to clinicians about liberation from the ventilator.

METHODS

Meta-analyses and comprehensive syntheses were used to thoroughly review, compile, and summarize the complete body of relevant evidence. All studies were meticulously assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) method, and the outcomes were presented succinctly as evidence profiles. Those evidence syntheses were discussed by a multidisciplinary committee of experts in mechanical ventilation, who then developed and approved recommendations.

RESULTS

Recommendations for nine PICO (population, intervention, comparator, and outcome) questions about ventilator liberation are presented in this document. This guideline includes seven conditional recommendations, one expert consensus recommendation, and one conditional deferred recommendation.

CONCLUSIONS

We developed these clinical guidelines for mechanical ventilation liberation to provide meaningful recommendations. These guidelines reflect the best treatment for patients seeking liberation from mechanical ventilation.

Effect of aggressive vs conservative screening and confirmatory test on time to extubation among patients at low or intermediate risk: a randomized clinical trial

PURPOSE

This study aimed to determine the best strategy to achieve fast and safe extubation.

METHODS

This multicenter trial randomized patients with primary respiratory failure and low-to-intermediate risk for extubation failure with planned high-flow nasal cannula (HFNC) preventive therapy. It included four groups: (1) conservative screening with ratio of partial pressure of arterial oxygen (PaO2) to fraction of inspired oxygen (FiO2) ≥ 150 and positive end-expiratory pressure (PEEP) ≤ 8 cmH2O plus conservative spontaneous breathing trial (SBT) with pressure support 5 cmH2O + PEEP 0 cmH2O); (2) screening with ratio of partial pressure of arterial oxygen (PaO2) to fraction of inspired oxygen (FiO2) ≥ 150 and PEEP ≤ 8 plus aggressive SBT with pressure support 8 + PEEP 5; (3) aggressive screening with PaO2/FiO2 > 180 and PEEP 10 maintained until the SBT with pressure support 8 + PEEP 5; (4) screening with PaO2/FiO2 > 180 and PEEP 10 maintained until the SBT with pressure support 5 + PEEP 0. Primary outcomes were time-to-extubation and simple weaning rate. Secondary outcomes included reintubation within 7 days after extubation.

RESULTS

Randomization to the aggressive-aggressive group was discontinued at the interim analysis for safety reasons. Thus, 884 patients who underwent at least 1 SBT were analyzed (conservative-conservative group, n = 256; conservative-aggressive group, n = 267; aggressive-conservative group, n = 261; aggressive-aggressive, n = 100). Median time to extubation was lower in the groups with aggressive screening (p < 0.001). Simple weaning rates were 45.7%, 76.78% (205 patients), 71.65%, and 91% (p < 0.001), respectively. Reintubation rates did not differ significantly (p = 0.431).

CONCLUSION

Among patients at low or intermediate risk for extubation failure with planned HFNC, combining aggressive screening with preventive PEEP and a conservative SBT reduced the time to extubation without increasing the reintubation rate.

Impact of different oxygen therapy strategies on the risk of endotracheal reintubation in mechanically ventilated patients: A systematic review and meta-analysis

BACKGROUND

Mechanical ventilation (MV) is a crucial intervention for the support of patients with acute and severe respiratory failure in modern intensive care medicine. However, the mechanical forces resulting from the interplay between the ventilator and the respiratory system may cause pulmonary injury.

OBJECTIVE

To compare the effects of high-flow nasal cannula (HFNC) therapy and other oxygen therapy modalities on the risk of endotracheal reintubation in mechanically ventilated patients after extubation in the intensive care unit (ICU).

METHODS

An electronic search was carried out across various databases including PubMed, Embase, Ovid, Medline, Cochrane Library, Embase, VIP, and Wanfang. The objective of this search was to locate prospective randomized controlled trials that examined the effects of multiple oxygen therapy approaches on the incidence of reintubation in patients in the ICU after undergoing mechanical ventilation. The meta package in R language was used to analyze parameters adopted by the included studies such as reintubation rate, mortality rate, and length of hospital stay.

RESULTS

This study enrolled 22 articles, involving 4,160 participants, with 2,061 in the study group and 2,099 in the control group. Among these, 20 articles presented data on the reintubation rate of the patients included with an odds ratio (OR) of 0.90 (95% CI: 0.74, 1.09) for HFNC and an OR of 1.77 (95% CI: 0.93, 3.38) for HFNC in the chronic obstructive pulmonary disease (COPD) subgroup. Moreover, 10 articles assessed the incidence of respiratory failure after extubation, revealing an OR for HFNC was 0.68 (95% CI: 0.55, 0.84) using a fixed-effects model. Nine articles addressed ICU mortality, while 13 pieces of literature examined hospital mortality. HFNC showed no significant impact on either ICU mortality or hospital mortality.

CONCLUSION

HFNC therapy markedly reduces the incidence of respiratory failure in mechanically ventilated patients following extubation in the ICU. Furthermore, it specifically reduces the risk of reintubation in patients diagnosed with COPD.

Heart Transplantation-Postoperative Considerations

Heart transplantation (HT) remains the best treatment of patients with severe heart failure who are deemed to be transplant candidates. The authors discuss postoperative management of the HT recipient by system, emphasizing areas where care might differ from other cardiac surgery patients. Working together, critical care physicians, heart transplant surgeons and cardiologists, advanced practice providers, pharmacists, transplant coordinators, nursing staff, physical therapists, occupational therapists, rehabilitation specialists, nutritionists, health psychologists, social workers, and the patient and their loved ones partner to increase the likelihood of a successful outcome.

Personalized Noninvasive Respiratory Support in the Perioperative Setting: State of the Art and Future Perspectives

Background: Noninvasive respiratory support (NRS), including high-flow nasal oxygen therapy (HFNOT), noninvasive ventilation (NIV) and continuous positive airway pressure (CPAP), are routinely used in the perioperative period. Objectives: This narrative review provides an overview on the perioperative use of NRS. Preoperative, intraoperative, and postoperative respiratory support is discussed, along with potential future areas of research. Results: During induction of anesthesia, in selected patients at high risk of difficult intubation, NIV is associated with improved gas exchange and reduced risk of postoperative respiratory complications. HFNOT demonstrated an improvement in oxygenation. Evidence on the intraoperative use of NRS is limited. Compared with conventional oxygenation, HFNOT is associated with a reduced risk of hypoxemia during procedural sedation, and recent data indicate a possible role for HFNOT for intraoperative apneic oxygenation in specific surgical contexts. After extubation, "preemptive" NIV and HFNOT in unselected cohorts do not affect clinical outcome. Postoperative "curative" NIV in high-risk patients and among those exhibiting signs of respiratory failure can reduce reintubation rate, especially after abdominal surgery. Data on postoperative "curative" HFNOT are limited. Conclusions: There is increasing evidence on the perioperative use of NRS. Use of NRS should be tailored based on the patient's specific characteristics and type of surgery, aimed at a personalized cost-effective approach.

Sex difference in the risk of extubation failure in ICUs

BACKGROUND

Little attention has been paid to potential differences in prognosis between mechanically ventilated males and females in intensive care units (ICUs). We hypothesized that a sex gap in the risk of extubation failure in ICUs may exist.

METHODS

Post hoc analysis of a large-scale clinical trial including patients at high risk of extubation failure in ICUs, with the aim of assessing the risk of extubation failure according to sex. The primary outcome was reintubation within the 7 days following extubation.

RESULTS

Out of 641 patients, 425 (66%) were males and 216 (34%) were females. Males were more likely to be admitted for cardiac arrest and to have underlying ischemic heart disease whereas females were more likely to be admitted for coma and to have obesity. Whereas the rate of reintubation at 48 h was significantly higher in males than in females (11.0% vs. 6.0%; difference, + 5.0 [95% CI, 0.2 to 9.2]; P = 0.038), the rate of reintubation at day 7 did not significantly differ between males and females (16.7% vs. 11.1%; difference, + 5.6% [95%CI, - 0.3 to 10.8], P = 0.059). Using multivariable logistic regression analysis, male sex was independently associated with reintubation within the 7 days following extubation (adjusted OR 1.70 [95% CI, 1.01 to 2.89]; P = 0.048), even after adjustment on reason for admission, body-mass index, severity score, respiratory rate before extubation, and noninvasive ventilation after extubation.

CONCLUSION

In this post hoc analysis of a clinical trial including a homogeneous subset of patients at high risk of extubation failure, sex was independently associated with reintubation. The role of sex on outcomes should be systematically examined in future studies of critically ill patients.

Decision Self-Efficacy and Decisional Conflict on Reintubation among Surrogates of Ventilated Patients Undergoing Planned Extubation

PURPOSE

Although the medical decision-making process can be overwhelming for some surrogates, there is a lack of understanding regarding their experiences. The objectives of this study were to examine the decision self-efficacy and decisional conflict experienced by surrogates in intensive care units (ICUs) when faced with the decision of whether to reintubate patients with respiratory failure after a planned extubation. In addition, predictors and mediators influencing these decision-making processes were identified.

METHODS

This study utilized a cross-sectional design to investigate the decision-making processes of 174 surrogates who were faced with the decision of whether to reintubate patients with respiratory failure after a planned extubation in the internal ICU of a medical center between August 2021 and February 2022. Structured questionnaires were administered to collect data on the surrogates' background information, decision self-efficacy, decisional conflict, and positive and negative affect. The patients' background information was also collected. Univariate and multivariate analyses were performed to model the data.

RESULTS

The mean decision self-efficacy score of the surrogates was 82.41 points, and 20.7% surrogates had decisional conflict scores exceeding 37.5 points, suggesting that they faced challenges in the decision-making process. Surrogates' employment status and negative affect significantly predicted their decision self-efficacy. In addition, patients' activities of daily living prior to hospitalization and the decision self-efficacy of the surrogate significantly predicted surrogate decisional conflict. The impact of surrogates' negative affect on decisional conflict was fully mediated by decision self-efficacy.

CONCLUSIONS

Surrogate decision self-efficacy mediates the relationship between negative affect and decisional conflict. Providing clinical care interventions that focus on enhancing surrogate self-efficacy and reducing negative affect can help alleviate decisional conflict in this population.

Physiological effects of high-flow nasal cannula oxygen therapy after extubation: a randomized crossover study

BACKGROUND

Prophylactic high-flow nasal cannula (HFNC) oxygen therapy can decrease the risk of extubation failure. It is frequently used in the postextubation phase alone or in combination with noninvasive ventilation. However, its physiological effects in this setting have not been thoroughly investigated. The aim of this study was to determine comprehensively the effects of HFNC applied after extubation on respiratory effort, diaphragm activity, gas exchange, ventilation distribution, and cardiovascular biomarkers.

METHODS

This was a prospective randomized crossover physiological study in critically ill patients comparing 1 h of HFNC versus 1 h of standard oxygen after extubation. The main inclusion criteria were mechanical ventilation for at least 48 h due to acute respiratory failure, and extubation after a successful spontaneous breathing trial (SBT). We measured respiratory effort through esophageal/transdiaphragmatic pressures, and diaphragm electrical activity (ΔEAdi). Lung volumes and ventilation distribution were estimated by electrical impedance tomography. Arterial and central venous blood gases were analyzed, as well as cardiac stress biomarkers.

RESULTS

We enrolled 22 patients (age 59 ± 17 years; 9 women) who had been intubated for 8 ± 6 days before extubation. Respiratory effort was significantly lower with HFNC than with standard oxygen therapy, as evidenced by esophageal pressure swings (5.3 [4.2-7.1] vs. 7.2 [5.6-10.3] cmH2O; p < 0.001), pressure-time product (85 [67-140] vs. 156 [114-238] cmH2O*s/min; p < 0.001) and ΔEAdi (10 [7-13] vs. 14 [9-16] µV; p = 0.022). In addition, HFNC induced increases in end-expiratory lung volume and PaO2/FiO2 ratio, decreases in respiratory rate and ventilatory ratio, while no changes were observed in systemic hemodynamics, Troponin T, or in amino-terminal pro-B-type natriuretic peptide.

CONCLUSIONS

Prophylactic application of HFNC after extubation provides substantial respiratory support and unloads respiratory muscles. Trial registration January 15, 2021. NCT04711759.

Assessing swallowing disorders in adults on high-flow nasal cannula in critical and non-critical care settings. A scoping review protocol

INTRODUCTION

The high-flow nasal cannula (HFNC) has become a widely used respiratory support system, which has proven to be effective in different populations. The facilitation of oral communication and feeding have been described as advantages of this support. Nevertheless, swallowing disorders associated with the use of HFNC have been postulated. However, such evidence is scattered in the literature, not systematically searched, and needs to be adequately summarised. This review aimed to explore the literature, to identify and map the evidence, regarding the frequency and methods of assessment of swallowing disorders in adult HFNC users, in both critical and non-critical units.

MATERIALS AND METHODS

A scoping review will be conducted. A systematic search in MEDLINE (Ovid), Embase (Ovid), CENTRAL, CINAHL (EBSCOhost), and other resources will be conducted. Primary studies, in any language or publication status, assessing the incidence of swallowing disorders in adults with HFNC support will be included. Two reviewers will independently select studies and extract data. Disagreements will be resolved by consensus or a third reviewer. The results will be reported narratively, using tables and figures to support them.

DISCUSSION

Positive end-expiratory pressure generated in the airway by HFNC could impair the proper swallowing performance. Knowing the methodological characteristics, the instruments or scales used to assess the presence of dysphagia, and the results of the studies may contribute to considering swallowing assessment in this population on a routine basis, as well as to guide the conduct of new studies that may respond to less researched areas in this topic.

REGISTRATION

Registration number: INPLASY2022110078.

Time definition of reintubation most relevant to patient outcomes in critically ill patients: a multicenter cohort study

BACKGROUND

Reintubation is a common complication in critically ill patients requiring mechanical ventilation. Although reintubation has been demonstrated to be associated with patient outcomes, its time definition varies widely among guidelines and in the literature. This study aimed to determine the association between reintubation and patient outcomes as well as the consequences of the time elapsed between extubation and reintubation on patient outcomes.

METHODS

This was a multicenter retrospective cohort study of critically ill patients conducted between April 2015 and March 2021. Adult patients who underwent mechanical ventilation and extubation in intensive care units (ICUs) were investigated utilizing the Japanese Intensive Care PAtient Database. The primary and secondary outcomes were in-hospital and ICU mortality. The association between reintubation and clinical outcomes was studied using Cox proportional hazards analysis. Among the patients who underwent reintubation, a Cox proportional hazard analysis was conducted to evaluate patient outcomes according to the number of days from extubation to reintubation.

RESULTS

Overall, 184,705 patients in 75 ICUs were screened, and 1849 patients underwent reintubation among 48,082 extubated patients. After adjustment for potential confounders, multivariable analysis revealed a significant association between reintubation and increased in-hospital and ICU mortality (adjusted hazard ratio [HR] 1.520, 95% confidence interval [CI] 1.359-1.700, and adjusted HR 1.325, 95% CI 1.076-1.633, respectively). Among the reintubated patients, 1037 (56.1%) were reintubated within 24 h after extubation, 418 (22.6%) at 24-48 h, 198 (10.7%) at 48-72 h, 111 (6.0%) at 72-96 h, and 85 (4.6%) at 96-120 h. Multivariable Cox proportional hazard analysis showed that in-hospital and ICU mortality was highest in patients reintubated at 72-96 h (adjusted HR 1.528, 95% CI 1.062-2.197, and adjusted HR 1.334, 95% CI 0.756-2.352, respectively; referenced to reintubation within 24 h).

CONCLUSIONS

Reintubation was associated with a significant increase in in-hospital and ICU mortality. The highest mortality rates were observed in patients who were reintubated between 72 and 96 h after extubation. Further studies are warranted for the optimal observation of extubated patients in clinical practice and to strengthen the evidence for mechanical ventilation.