Non-invasive ventilation versus high-flow nasal oxygen for postextubation respiratory failure in ICU: a post-hoc analysis of a randomized clinical trial
Authors: Thille Arnaud W. , Monseau Grégoire , Coudroy Rémi , Nay Mai-Anh , Gacouin Arnaud , Decavèle Maxens , Sonneville Romain , Beloncle François , Girault Christophe , Dangers Laurence , Lautrette Alexandre , Levrat Quentin , Rouzé Anahita , Vivier Emmanuel , Lascarrou Jean-Baptiste , Ricard Jean-Damien , Razazi Keyvan , Barberet Guillaume , Lebert Christine , Ehrmann Stephan , Massri Alexandre , Bourenne Jeremy , Pradel Gael , Bailly Pierre , Terzi Nicolas , Dellamonica Jean , Lacave Guillaume , Robert René , Ragot Stéphanie , Frat Jean-Pierre ,   for the HIGH-WEAN Study Group and the REVA research network, Boissier Florence , Chatellier Delphine , Deletage Céline , Guignon Carole , Joly Florent , Olivry Morgane , Veinstein Anne , Benzekri-Lefevre Dalila , Boulain Thierry , Muller Grégoire , Le Tulzo Yves , Tadié Jean-Marc , Maamar Adel , Demiri Suela , Mayaux Julien , Demoule Alexandre , Bouadma Lila , Dupuis Claire , Asfar Pierre , Pierrot Marc , Béduneau Gaëtan , Boyer Déborah , Delmas Benjamin , Puech Bérénice , Bachoumas Konstantinos , Soum Edouard , Cabasson Séverin , Hoppe Marie-Anne , Nseir Saad , Pouly Olivier , Bourdin Gaël , Rosselli Sylvène , Le Meur Anthony , Garret Charlotte , Martin Maelle , Berquier Guillaume , Thiagarajah Abirami , Carteaux Guillaume , Mekontso-Dessap Armand , Poidevin Antoine , Dureau Anne-Florence , Azais Marie-Ange , Colin Gwenhaël , Mercier Emmanuelle , Morisseau Marlène , Sabatier Caroline , Picard Walter , Gainnier Marc , Nguyen Thi-My-Hue , Prat Gwenaël , Schwebel Carole , Buscot Matthieu 
Published: June 2021

Abstract
Background
In intensive care units (ICUs), patients experiencing post-extubation respiratory failure have poor outcomes. The use of noninvasive ventilation (NIV) to treat post-extubation respiratory failure may increase the risk of death. This study aims at comparing mortality between patients treated with NIV alternating with high-flow nasal oxygen or high-flow nasal oxygen alone.

Methods
Post-hoc analysis of a multicenter, randomized, controlled trial focusing on patients who experienced post-extubation respiratory failure within the 7 days following extubation. Patients were classified in the NIV group or the high-flow nasal oxygen group according to oxygenation strategy used after the onset of post-extubation respiratory failure. Patients reintubated within the first hour after extubation and those promptly reintubated without prior treatment were excluded. The primary outcome was mortality at day 28 after the onset of post-extubation respiratory failure.

Results
Among 651 extubated patients, 158 (25%) experienced respiratory failure and 146 were included in the analysis. Mortality at day 28 was 18% (15/84) using NIV alternating with high-flow nasal oxygen and 29% (18/62) with high flow nasal oxygen alone (difference, − 11% [95% CI, − 25 to 2]; p = 0.12). Among the 46 patients with hypercapnia at the onset of respiratory failure, mortality at day 28 was 3% (1/33) with NIV and 31% (4/13) with high-flow nasal oxygen alone (difference, − 28% [95% CI, − 54 to − 6]; p = 0.006). The proportion of patients reintubated 48 h after the onset of post-extubation respiratory failure was 44% (37/84) with NIV and 52% (32/62) with high-flow nasal oxygen alone (p = 0.21).

Conclusions
In patients with post-extubation respiratory failure, NIV alternating with high-flow nasal oxygen might not increase the risk of death.
Trial registration number
The trial was registered at http://www.clinicaltrials.gov with the registration number NCT03121482 the 20th April 2017.