Postextubation High-Flow Nasal Oxygen With Noninvasive Ventilation vs High-Flow Nasal Oxygen Alone
Thille 2019 trial design and results
Design
Multicentre randomised clinical trial
Treatment
High-flow nasal oxygen alternating with non-invasive ventilation
Control
High-flow nasal oxygen alone
Population
648 patients at high risk of extubation failure, mean age 70, 34% women
Follow-up
7 days
Primary endpoint
Reintubation at day 7
Result
Reintubation at day 7 occurred in 40 of 339 (11.8%, 95% CI 8.4% to 15.2%) with high-flow oxygen plus non-invasive ventilation versus 55 of 302 (18.2%, 13.9% to 22.6%) with high-flow oxygen alone — difference -6.4 percentage points (95% CI -12.0 to -0.9, p=0.02). ICU mortality did not differ significantly: 6% with high-flow oxygen plus non-invasive ventilation versus 9% with high-flow oxygen alone (difference -2.4%, 95% CI -6.7 to 1.7).
In mechanically ventilated patients at high risk of extubation failure, the use of high-flow nasal oxygen with NIV immediately after extubation significantly decreased the risk of reintubation compared with high-flow nasal oxygen alone.
The trial authors, in the published abstract
How it has aged
Builds on Hernandez 2016 rather than contradicting it: high-flow oxygen is the base, and non-invasive ventilation is added for the very highest risk. Note this is prophylaxis in selected patients again, not rescue — the distinction Esteban 2004 made expensive to ignore.
Publications
Effect of Postextubation High-Flow Nasal Oxygen With Noninvasive Ventilation vs High-Flow Nasal Oxygen Alone on Reintubation Among Patients at High Risk of Extubation Failure: A Randomized Clinical Trial
Thille AW, Muller G, Gacouin A, et al. Effect of Postextubation High-Flow Nasal Oxygen With Noninvasive Ventilation vs High-Flow Nasal Oxygen Alone on Reintubation Among Patients at High Risk of Extubation Failure: A Randomized Clinical Trial. JAMA 2019 Oct 15;322(15):1465-1475.
Reintubation at day 7 reduced from 18.2% to 11.8%
Benefit confined to patients at high risk of extubation failure