Arrive, François (F);Le Pape, Sylvain (S);Bruhn, Alejandro (A);Pépin Lehalleur, Adrien (A);Beuvon, Clément (C);Tuffet, Samuel (S);Etien, Erik (E);Rambault, Laurent (L);Frat, Jean-Pierre (JP);Coudroy, Rémi (R);Thille, Arnaud W (AW);

Author information

Crit Care.2025 May 08;29(1):185.doi:10.1186/s13054-025-05366-y

Abstract

BACKGROUND: Extubation failure leading to reintubation is associated with high mortality. In patients at high-risk of extubation failure, clinical practice guidelines recommend prophylactic non-invasive ventilation (NIV) over high-flow nasal oxygen (HFNO) immediately after extubation. However, the physiological effects supporting the beneficial effect of NIV have been poorly explored. We hypothesized that NIV may reduce patient inspiratory efforts to a greater extent than HFNO after extubation.

METHODS: In a prospective physiological study, patients at high-risk of extubation failure (> 65 years old or underlying cardiac or respiratory disease) were included to receive after planned extubation prophylactic NIV and HFNO in a randomized crossover order, followed by standard oxygen. Inspiratory efforts were assessed by calculation of the simplified esophageal pressure-time-product per minute (sPTP in cmHO s/min). Tidal volumes, distribution and homogeneity of ventilation were estimated using electrical impedance tomography.

RESULTS: Twenty patients were retained in the analysis. Inspiratory efforts were lower with NIV than with HFNO (sPTP 196 cm HO s/min [116-234] vs. 220 [178-327], p < 0.001) whereas tidal volumes were larger with NIV than with HFNO (8.4 mL/kg of predicted body weight [6.7-9.9] vs. 6.9 [5.3-8.6], p = 0.005). There was a non-significant increase in dorsal region ventilation under NIV compared to HFNO.

CONCLUSIONS: In patients at high-risk of extubation failure, prophylactic NIV significantly decreased inspiratory efforts with increased tidal volumes compared to HFNO. The clinical benefits of NIV to prevent reintubation in patients at high-risk may be mediated by these physiological effects. Trial registration Clinicaltrials.gov: ID NCT04036175), retrospectively registered 17 June 2019.