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Randomized Controlled Trial
. 2025 May 8;29(1):185.
doi: 10.1186/s13054-025-05366-y.

Physiological comparison of noninvasive ventilation and high-flow nasal oxygen on inspiratory efforts and tidal volumes after extubation: a randomized crossover trial

François Arrive  1 , Sylvain Le Pape  2   3 , Alejandro Bruhn  4   5 , Adrien Pépin Lehalleur  2 , Clément Beuvon  2 , Samuel Tuffet  6 , Erik Etien  7 , Laurent Rambault  7 , Jean-Pierre Frat  2   3 , Rémi Coudroy  2   3 , Arnaud W Thille  2   3
Affiliations
Randomized Controlled Trial

Physiological comparison of noninvasive ventilation and high-flow nasal oxygen on inspiratory efforts and tidal volumes after extubation: a randomized crossover trial

François Arrive et al. Crit Care. .

Abstract

Background: Extubation failure leading to reintubation is associated with high mortality. In patients at high-risk of extubation failure, clinical practice guidelines recommend prophylactic non-invasive ventilation (NIV) over high-flow nasal oxygen (HFNO) immediately after extubation. However, the physiological effects supporting the beneficial effect of NIV have been poorly explored. We hypothesized that NIV may reduce patient inspiratory efforts to a greater extent than HFNO after extubation.

Methods: In a prospective physiological study, patients at high-risk of extubation failure (> 65 years old or underlying cardiac or respiratory disease) were included to receive after planned extubation prophylactic NIV and HFNO in a randomized crossover order, followed by standard oxygen. Inspiratory efforts were assessed by calculation of the simplified esophageal pressure-time-product per minute (sPTPes in cmH2O s/min). Tidal volumes, distribution and homogeneity of ventilation were estimated using electrical impedance tomography.

Results: Twenty patients were retained in the analysis. Inspiratory efforts were lower with NIV than with HFNO (sPTPes 196 cm H2O s/min [116-234] vs. 220 [178-327], p < 0.001) whereas tidal volumes were larger with NIV than with HFNO (8.4 mL/kg of predicted body weight [6.7-9.9] vs. 6.9 [5.3-8.6], p = 0.005). There was a non-significant increase in dorsal region ventilation under NIV compared to HFNO.

Conclusions: In patients at high-risk of extubation failure, prophylactic NIV significantly decreased inspiratory efforts with increased tidal volumes compared to HFNO. The clinical benefits of NIV to prevent reintubation in patients at high-risk may be mediated by these physiological effects. Trial registration Clinicaltrials.gov: ID NCT04036175), retrospectively registered 17 June 2019.

Keywords: Airway extubation; Noninvasive ventilation; Ventilator weaning; Work of breathing.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: The study was approved by the ethics committee (Comité de Protection des Personnes, CPP Est III) with registration number 2017-A02838-45. In keeping with our national regulation, consent from patients or agreement from their surrogate was obtained orally with a written record maintained by the researcher. The study protocol was retrospectively recorded at clinicaltrials.gov (ID: NCT04036175) on the 17th of June, 2019. Competing interests: JPF receveid grants from the French Ministry of Health; personal fees for lectures, travel expense coverage to attend scientific meetings, grant for randomized clinical trial from Fisher and Paykel Healthcare; personal fees as member of a scientific board and travel expense coverage to attend scientific meetings from SOS Oxygène outside this work. RC received personal fees from Fisher & Paykel Healthcare and Löwenstein, reimbursement for travel expenses from Fisher & Paykel Healthcare, stakeholder of Mayan pharma AT received personal fees for lectures and travel expanse coverage to attend scientific meetings from Fisher&Paykel. FA, SLP, AB, APL, CB, ST, EE, LR declare no competing interests. RC received personal fees from Fisher & Paykel Healthcare and Löwenstein, reimbursement for travel expenses from Fisher & Paykel Healthcare, stakeholder of Mayan pharma. AT received personal fees for lectures and travel expanse coverage to attend scientific meetings from Fisher&Paykel. FA, SLP, AB, APL, CB, EE, LR, ST declare no competing interests.

Figures

Fig. 1
Fig. 1
Flow-chart. Patients were included across five distinct periods between 2018 and 2023 for a total of 19 months
Fig. 2
Fig. 2
Comparison of patient inspiratory efforts to the different respiratory supports: patient inspiratory efforts were significantly lower with noninvasive ventilation than with high-low nasal cannula oxygen and standard oxygen
Fig. 3
Fig. 3
Comparison of tidal volumes according to the different respiratory supports: tidal volumes were significantly larger with noninvasive ventilation (NIV) than with high-flow nasal oxygen (HFNO)
See this image and copyright information in PMC

References

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