ArticlesNon-invasive ventilation after extubation in hypercapnic patients with chronic respiratory disorders: randomised controlled trial
Introduction
Reintubation is sometimes necessary for management of respiratory failure after extubation1 and is undertaken in 6–23% of patients within 48–72 h of planned extubation.2, 3, 4 Although reintubation could indicate increased disease severity, it is an independent risk factor for nosocomial pneumonia,5 mortality, and extended hospital stay.2
Findings of a case-control study6 suggest that non-invasive ventilation could be a promising treatment for respiratory failure after extubation, with potential to avoid reintubation.7 However, some concerns have been raised about use of non-invasive ventilation because in two randomised clinical trials in mixed populations, non-invasive ventilation was not beneficial in decreasing the risk of reintubation for patients who developed respiratory failure after extubation.1, 8 By contrast, non-invasive ventilation implemented immediately after planned extubation was effective at avoiding respiratory failure in people at high risk of this complication who had tolerated a spontaneous breathing trial.9, 10 Subgroup analysis showed that the benefits of non-invasive ventilation at enhancing survival were restricted to patients with hypercapnia (partial pressure of arterial carbon dioxide [PaCO2] >45 mm Hg) during the spontaneous breathing trial before extubation.10 In this subset of patients, 98% had underlying chronic respiratory disorders.
Findings of an adequately powered clinical trial should be able to show benefits of non-invasive ventilation after extubation in a hypercapnic population for several reasons. First, definitive conclusions can be drawn, unlike with subgroup analyses. Second, the numbers of patients with hypercapnia enrolled into the study can be controlled, by comparison with low numbers recorded in previous subgroup analyses.10 Finally, non-invasive ventilation is an effective treatment for patients with acute-on-chronic hypercapnic respiratory failure.11
We postulated that early use of non-invasive ventilation during the initial period after extubation would avert respiratory failure and enhance survival of patients with chronic respiratory disorders who had hypercapnia during a spontaneous breathing trial before extubation. Therefore, we aimed to assess the effectiveness of this strategy compared with conventional oxygen management in patients who underwent planned extubation.
Section snippets
Patients
We undertook a randomised controlled trial in the respiratory and medical intensive-care units of Hospital Clinic, Barcelona, and in the general intensive-care unit of Hospital Morales Meseguer, Murcia, Spain. All patients with chronic respiratory disorders, intubated for 48 h or more, who tolerated a spontaneous breathing trial through a T-piece after recovery of their disease, with hypercapnic respiratory failure (PaCO2 >45 mm Hg) on spontaneous breathing, were deemed eligible for the study.
Results
Between May, 2005, and December, 2007, 164 consecutive patients were registered for the study, of whom 106 underwent random allocation (figure 1). 54 were allocated non-invasive ventilation and 52 were assigned control. General clinical characteristics and physiological variables of patients at entry into the study did not differ at baseline (Table 1, Table 2).
Non-invasive ventilation was delivered for a mean period of 18 h (SD 7) in patients assigned to this group. Mean levels of inspiratory
Discussion
The results of our study confirm the benefits of early use of non-invasive ventilation after extubation to diminish risk of respiratory failure in patients with chronic respiratory disorders and hypercapnia during a spontaneous breathing trial. This strategy resulted in lowered mortality in our population.
This specific population is at high risk of development of respiratory failure after extubation, confirmed by a frequency of 48% in the control group, similar to a 41% rate recorded in a
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