Multidisciplinary Intensive Care Unit, Department of Anaesthesiology and Critical Care Medicine, La Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, Sorbonne University, GRC 29, DMU DREAM, Paris, France.
Adult Intensive Care Unit, Department of Peri-Operative Medicine, University Hospital Estaing, University of Auvergne, Clermont-Ferrand, France.
Crit Care. 2024 Nov 26;28(1):391. doi: 10.1186/s13054-024-05166-w.
Postextubation respiratory failure (PRF) frequently complicates weaning from mechanical ventilation and may increase morbidity/mortality. Noninvasive ventilation (NIV) alternating with high-flow nasal oxygen (HFNO) may prevent PRF.
Ventilated patients without chronic obstructive pulmonary disease (COPD) and at high-risk of PRF defined as a lung ultrasound score (LUS) ≥ 14 assessed during the spontaneous breathing trial, were included in a French-Chinese randomised controlled trial. PRF was defined by 2 among the following signs: SpO < 90%; Respiratory rate > 30 /min; hypercapnia; haemodynamic and/or neurological disturbances of respiratory origin. In the intervention group, prophylactic NIV alternating with HFNO was administered for 48 h following extubation. In the control group, conventional oxygen was used. Clinicians were informed on the LUS in the intervention group, those in the control group remained blind. The primary outcome was the incidence of PRF 48 h after extubation. Secondary outcomes were incidence of PRF and reintubation at day 7, number of ventilator-free days at day 28, length of ICU stay and mortality at day 28 and 90.
Two hundred and forty patients were randomised and 227 analysed (intervention group = 128 and control group = 99). PRF at H48 was reduced in the intervention group compared to the control group: relative risk 0.52 (0.31 to 0.88), p = 0.01. The benefit persisted at day 7: relative risk 0.62 (0.44 to 0.96), p = 0.02. Weaning failure imposing reconnection to mechanical ventilation was not reduced. In patients who developed PRF and were treated by rescue NIV, reintubation was avoided in 44% of control patients and in 12% of intervention patients (p = 0.008). Other secondary outcomes were not different between groups. From a resource utilisation standpoint, prophylactic NIV alternating with HFNO was more demanding and costly than conventional oxygen with rescue NIV to achieve same clinical outcome.
Compared to conventional oxygenation, prophylactic NIV alternating with HFNO significantly reduced postextubation respiratory failure but failed to reduce reintubation rate and mortality in patients without COPD at high risk of extubation failure. Prophylactic NIV alternating with HFNO was as efficient as recue NIV to treat postextubation respiratory failure.
拔管后呼吸衰竭（PRF）常并发于机械通气撤机过程中，并可能增加发病率/死亡率。无创通气（NIV）与高流量鼻氧（HFNO）交替使用可能预防 PRF。
本研究纳入了一项法国-中国的随机对照试验，纳入了无慢性阻塞性肺疾病（COPD）且有 PRF 高危风险的机械通气患者（在自主呼吸试验期间评估的肺部超声评分（LUS）≥14）。PRF 定义为以下 2 个征象中的 2 个：SpO₂＜90%；呼吸频率＞30 次/分；高碳酸血症；呼吸源性血流动力学和/或神经功能紊乱。在干预组中，在拔管后 48 小时内给予预防性 NIV 与 HFNO 交替治疗。在对照组中，常规吸氧。干预组的临床医生了解 LUS 情况，对照组的临床医生保持盲法。主要结局为拔管后 48 小时内 PRF 的发生率。次要结局为第 7 天 PRF 和再插管的发生率、第 28 天无呼吸机天数、ICU 住院时间和第 28 天和第 90 天死亡率。
240 例患者随机分组，227 例患者进行分析（干预组 128 例，对照组 99 例）。与对照组相比，干预组在 H48 时 PRF 发生率降低：相对风险 0.52（0.31 至 0.88），p=0.01。该获益在第 7 天仍持续：相对风险 0.62（0.44 至 0.96），p=0.03。未降低因撤机失败而重新连接机械通气的拔管失败率。在发生 PRF 并接受抢救性 NIV 治疗的患者中，对照组有 44%的患者避免了再插管，而干预组有 12%的患者避免了再插管（p=0.008）。两组的其他次要结局无差异。从资源利用的角度来看，与常规氧疗相比，预防性 NIV 与 HFNO 交替使用在无 COPD 且有拔管失败高风险的患者中，虽能显著降低拔管后呼吸衰竭的发生率，但不能降低再插管率和死亡率。预防性 NIV 与 HFNO 交替使用与抢救性 NIV 治疗拔管后呼吸衰竭同样有效。
