Oxygenation strategies after extubation of critically ill and postoperative patients

Abstract

In intensive care units (ICUs), the decision to extubate is a critical one because mortality is particularly high in case of reintubation. Around 15% of patients ready to be weaned off a ventilator experience extubation failure leading to reintubation. The use of high-flow nasal oxygen and non-invasive ventilation are two alternatives of standard oxygen supplementation that may help to prevent reintubation. High-flow nasal oxygen and non-invasive ventilation, may be used to prevent reintubation in patients with low (e.g., patients without comorbidities and with short durations of mechanical ventilation) and high risk (e.g., patients >65 years and those with underlying cardiac disease, chronic respiratory disorders, and/or hypercapnia at the time of extubation) of reintubation, respectively. However, non-invasive ventilation used as a rescue therapy to treat established post-extubation respiratory failure could increase mortality by delaying reintubation, and should therefore be used very carefully in this setting. The oxygenation strategy to be applied in postoperative patients is different from the patients who are extubated in the ICUs. Standard oxygen after a surgical procedure is adequate, even following major abdominal or cardiothoracic surgery, but should probably be switched to high-flow nasal oxygen in patients with hypoxemic. Unlike in patients experiencing post-extubation respiratory failure in ICUs wherein non-invasive ventilation may have deleterious effects, it may actually improve the outcomes in postoperative patients with respiratory failure. This review discusses the different clinical situations with the aim of choosing the most effective oxygenation strategy to prevent post-extubation respiratory failure and to avoid reintubation.

Keywords: Airway extubation; High-flow nasal oxygen therapy; Intensive care unit; Mechanical ventilation; Noninvasive ventilation; Ventilator weaning.

Fig. 1

Proposal of management of oxygenation strategies to prevent or treat respiratory failure in patients extubated in ICUs and in postoperative patients.ICUs: Intensive care units.

Fig. 2

Effect of non-invasive ventilation on reintubation rate (A) and on mortality rate (B) when compared with standard oxygen or high-flow nasal oxygen. By pooling the main multicenter, randomized controlled trials, the prophylactic use of non-invasive ventilation immediately after extubation is associated with reduced risk of reintubation (A) and decreased risk of death (B) in ICU. ICU: Intensive care unit.