Ventilation & weaning · Preventing post-extubation failure
Protocolized Postextubation Respiratory Support to Prevent Reintubation
| Design | Pragmatic, two-armed, cluster-crossover trial in a single academic medical ICU |
|---|---|
| Treatment | Respiratory therapist-driven protocol applying post-extubation support to all patients |
| Control | Post-extubation management at the discretion of treating clinicians |
| Population | 751 adults undergoing extubation from invasive mechanical ventilation |
| Follow-up | 96 hours after extubation |
| Primary endpoint | Reintubation within 96 hours of extubation |
| Result | Post-extubation support was given to 331 of 359 (92.2%) under the protocol versus 66 of 392 (16.8%) with usual care, driven by high-flow nasal cannula use (74.7% versus 2.8%). Reintubation occurred in 57 (15.9%) versus 52 (13.3%) — odds ratio 1.23 (95% CI 0.82 to 1.84, p=0.32). |
| Secondary endpoints | Time to reintubation, ICU and hospital length of stay |
Among a broad population of critically ill adults undergoing extubation from invasive mechanical ventilation at an academic medical center, protocolized postextubation respiratory support, primarily characterized by an increase in the use of high-flow nasal cannula, did not prevent reintubation compared with usual care.
The trial authors, in the published abstract
The counterweight to Hernandez 2016 and Thille 2019: those trials selected high-risk patients, this one treated everybody, and the benefit vanished. Post-extubation support is a targeted therapy, not a universal one.
Casey JD, Vaughan EM, Lloyd BD, et al. Protocolized Postextubation Respiratory Support to Prevent Reintubation: A Randomized Clinical Trial. Am J Respir Crit Care Med 2021 Aug 1;204(3):294-302.