Structure Literature Review to Assess the Appropriate Non-Invasive Respiratory Support for Post Extubation Management: HFNC VS NIV in High-Risk Patients

Abstract

Background and Rationale: Reintubation following planned extubation is a serious complication that can lead to a mortality risk of up to 50% in critically ill patients. It has been described to occur in 5 to 10% of all ICU patients after planned extubation. This rate can reach 30% in high-risk patients, such as those with chronic cardiorespiratory diseases. Therefore, identifying those who are at risk of extubation failure and prophylactically using the appropriate non-invasive respiratory support (NRS) is essential to reduce this risk. In my unit protocol, both non-invasive ventilation (NIV) and high-flow nasal cannula (HFNC) are recommended for post-extubation management, but no clear guidance exists on which NRS would be more effective in high-risk patients. Several studies have demonstrated the superiority of NIV over conventional oxygen therapy (COT) in reducing reintubation and preventing post-extubation respiratory failure (PERF) in high-risk patients. However, NIV has several complications, such as claustrophobia, discomfort, and skin injuries, which limit its applications in high-risk patients. Therefore, studies have investigated the non-inferiority of HFNC to NIV and found that HFNC was non-inferior to NIV in reducing reintubation rates in high-risk patients. Despite these findings, two recent guidelines have provided conflicting recommendations regarding the use of NIV and HFNC in high-risk patients. Therefore, I conducted this structured literature review to understand better which NRS is appropriate for high-risk patients following extubation. Method: I systematically searched three databases, namely Medline (via Ovid), Embase, and CENTRAL, from 2007 to 2024, using a developed list of keywords to identify RCTs that compare the effectiveness of HFNC to NIV in reducing reintubation rates in high-risk patients. I also developed eligibility criteria using PICOs framework to include relevant RCTs and evaluating their quality using the CASP tool. Results: I Included eight RCTs in my review; one study investigated a broad range of risk factors for extubation failure, one study included high-risk patients with sepsis, one study had more restricted risk factors for extubation failure, two studies included COPD patients, and three studies had patients with more than four risk factors for extubation failure. Conclusion: HFNC may be non-inferior to NIV in reducing reintubation in general high-risk patients, including those over 65 years old, with high severity of illness, excessive secretion, prolonged mechanical ventilation, or sepsis. However, NIV seems to be the appropriate strategy when patients have chronic cardiorespiratory diseases, hypercapnia at extubation, and several risk factors for extubation failure.