High-flow nasal cannula to prevent postextubation respiratory failure in high-risk non-hypercapnic patients: a randomized multicenter trial

Introduction: The use of high-flow nasal cannulas (HFNC) in patients with hypoxemic ventilatory failure reduces the need for mechanical ventilation and does not increase mortality when intubation is promptly applied. The aim of the study is to describe the behavior of HFNC in patients who live at high altitudes, and the performance of predictors of success/failure of this strategy. Methods: Prospective multicenter cohort study, with patients aged over 18 years recruited for 12 months in 2020 to 21. All had a diagnosis of hypoxemic respiratory failure secondary to pneumonia, were admitted to intensive care units, and were receiving initial management with a high-flow nasal cannula. The variables assessed included need for intubation, mortality in ICU, and the validation of SaO2, respiratory rate (RR) and ROX index (IROX) as predictors of HFNC success / failure. Results: One hundred and six patients were recruited, with a mean age of 59 years and a success rate of 74.5%. Patients with treatment failure were more likely to be obese (BMI 27.2 vs 25.5; OR: 1.03; 95% CI: .95-1.1) and had higher severity scores at admission (APACHE II 12 vs 20; OR 1.15; 95% CI: 1.06-1.24). Respiratory rates after 12 (AUC .81 CI: .70-.92) and 18 h (AUC .85 CI: .72-0.90) of HFNC use were the best predictors of failure, performing better than those that included oxygenation. ICU mortality was higher in the failure group (6% vs 29%; OR 8.8; 95% CI:1.75-44.7). Conclusions: High-flow oxygen cannula therapy in patients with hypoxemic respiratory failure living at altitudes above 2600 m is associated with low rates of therapy failure and a reduced need for mechanical ventilation in the ICU. The geographical conditions and secondary physiological changes influence the performance of the traditionally validated predictors of therapy success. Respiratory rate <30 proved to be the best indicator of early success of the device at 12 h of use.

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Readiness Assessment for Extubation Planning in the Intensive Care Unit: A Quality Improvement Initiative

Critical Care Nurse ◽

10.4037/ccn2021912 ◽

2021 ◽

Vol 41 (3) ◽

pp. 42-48

Author(s):

Jace D. Johnny

Keyword(s):

High Risk ◽

Failure Rate ◽

Noninvasive Ventilation ◽

Extubation Failure ◽

High Flow ◽

Nasal Cannula ◽

High Flow Nasal Cannula ◽

Prophylactic Measure ◽

High Risk Patients ◽

Risk Patients

Background Extubation failure is the reintubation of patients meeting criteria for weaning from mechanical ventilation. Extubation failure is correlated with mortality, prolonged mechanical ventilation, and longer hospital stays. Noninvasive ventilation or high-flow nasal cannula oxygen therapy after extubation is recommended to prevent extubation failure in high-risk patients. Local Problem The extubation failure rate is unknown. Prophylactic measures (noninvasive ventilation or high-flow nasal cannula) after extubation are not commonly used and vary among clinicians. The objective was to assess extubation planning readiness by determining extubation failure rate, identifying high-risk patients, and determining prophylactic measure compliance. Methods A quality improvement initiative included an evidence-based extubation failure risk assessment that identified high-risk patients and determined prophylactic measure compliance. A 2-year retrospective medical record review was used to determine baseline patient characteristics and extubation failure rate. Results Extubation failure rate within the retrospective cohort was 13 of 146 patients (8.9%). Extubation failure did not correlate with previously identified risk factors; however, 150 identified patients were excluded from analysis. During risk assessment integration, the extubation failure rate was 3 of 37 patients (8.1%) despite identifying 24 high-risk patients (65%). Few high-risk patients received prophylactic measures (noninvasive ventilation, 17%; high-flow nasal cannula, 12%). Conclusions Extubation failure should be routinely measured because of its effects on patient outcomes. This project reveals the multifactorial nature of extubation failure. Further research is needed to assess patients’ risk and account for acute conditions. This project used best practice guidelines for routine patient care and added transparency to a previously unmeasured event.

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