Randomized Controlled Trial

. 2025 Nov;135(5):1477-1485.

doi: 10.1016/j.bja.2025.09.002. Epub 2025 Oct 3.

Noninvasive ventilation in postoperative critically ill patients with morbid obesity: secondary analysis of the EXTUBOBESE multicentre randomised clinical trial

Audrey De Jong¹, Helena Huguet², Anne Bignon³, François Stephan⁴, Thomas Godet⁵, Lucie Collet⁶, Karim Asehnoune⁷, Aude Sylvestre⁸, Juliette Sautillet⁹, Raiko Blondonnet⁵, Martine Ferrandiere¹⁰, Yoann Launey¹¹, Sigismond Lasocki¹², Amélie Rollé¹³, Pierre-Marie Fayolle¹⁴, Laurent Muller¹⁵, Emmanuel Pardo¹⁶, Nicolas Terzi¹⁷, Séverin Ramin¹⁸, Boris Jung¹⁹, Emmanuel Weiss²⁰, Paer-Selim Abback²¹, Philippe Guerci²², Benjamine Sarton²³, Hadrien Rozé²⁴, Claire Dupuis²⁵, Joel Cousson²⁶, Marion Faucher²⁷, Virginie Lemiale²⁸, Bernard Cholley²⁹, Gerald Chanques¹, Fouad Belafia¹, Claire Chauveton³⁰, Emmanuel Futier⁵, Elie Azoulay²⁸, Nicolas Molinari³¹, Samir Jaber³²; EXTUB-OBESE trial group

Collaborators, Affiliations

Collaborators

EXTUB-OBESE trial group:
Boris Jung, Claudine Gniadek, Aurélie Vonarb, Albert Prades, Carine Jaillet, Samir Jaber, Gérald Chanques, Fouad Belafia, Audrey De Jong, Séverin Ramin, Xavier Capdevila, Jonathan Charbit, François Stephan, Thibaut Genty, Saida Rezaiguia-Delclaux, Audrey Imbert, Catherine Pilorge, Calypso Roman, Astrid Bouteau-Durand, Amélie Rollé, Michel Carles, Pierre-Marie Fayolle, Hossen Mehdaoui, Juliette Sautillet, Bertrand Souweine, Laure Calvet, Claire Dupuis, Thomas Godet, Matthieu Jabaudon, Emmanuel Futier, Raiko Blondonnet, Benjamin Rieu, Nicolas Terzi, Clara Candille, Florian Sigaud, Béatrice Riu, Benjamine Sarton, Sigismond Lasocki, Laurent Papazian, Aude Sylvestre, Sabine Valera, Djamel Mokart, Laurent Chow Chine, Magali Bisbal, Camille Pouliquen, Jean-Manuel de Guibert, Maxime Tourret, Damien Mallet, Marc Léone, Laurent Zieleskiewicz, Virginie Lemiale, Elie Azoulay, Philippe Seguin, Yoann Launey, Jeanne Cossic, Joel Cousson, Mona Assefi, Elodie Baron, Lucie Collet, Cyril Quemeneur, Antoine Monsel, Jean-Michel Constantin, Matthieu Biais, Hadrien Rozé, Alexandre Ouattara, Eline Bonnardel, Simon Monziols, Martin Mahul, Laurent Muller, Jean-Yves Lefrant, Claire Roger, Saber Barbar, Martine Ferrandière, Fabien Lambiotte, Piehr Saint-Léger, Paer-Selim Abback, Catherine Paugam, Emmanuel Weiss, Julien Pottecher, Pierre-Olivier Ludes, Karim Asehnoune, Emmanuel Pardo, Lucie Darrivere, Marc Garnier, Anne Bignon, Eric Kipnis, Gilles Lebuffe, Matthias Garot, Jeremy Falcone, Benjamin Chousterman, Magali Collet, Etienne Gayat, Philippe Guerci, Jean Dellamonica, Willy-Serge Mfam, Bernard Cholley, Evelina Ochin, Mohamed Nebli, Nejla Tilouche, Benjamin Madeux, David Bougon, Yassir Aarab, Fanny Garnier

Affiliations

¹ Department of Anaesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, Saint-Éloi Hospital, Montpellier, France.
² Clinical Research and Epidemiology Unit, University of Montpellier, CHU Montpellier, Montpellier, France.
³ CHU Lille, Reanimation Chirurgical, Lille, France.
⁴ Surgical Intensive Care Unit, Marie Lannelongue Hospital, Saclay University, School of Medicine, Le Plessis-Robinson, France.
⁵ Department of Peri-Operative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France.
⁶ Department of Anaesthesiology and Critical Care, Sorbonne University, Pitié-Salpêtrière Hospital, Paris, France.
⁷ Department of Anaesthesia and Critical Care, Hôtel Dieu, University Hospital of Nantes, Nantes, France.
⁸ Assistance Publique - Hôpitaux de Marseille, Hôpital Nord, Department of Intensive Care Medicine, Aix-Marseille University, Faculty of Medicine, Centre d'Études et de Recherches sur les Services de Santé et Qualité de Vie, Marseille, France.
⁹ Department of Intensive Care, Papeete Hospital, Tahiti, French Polynesia.
¹⁰ Department of Anaesthesia and Intensive Care, University of Tours, CHU Tours, Tours, France.
¹¹ Department of Anaesthesia and Intensive Care, University of Rennes, CHU Rennes, Rennes, France.
¹² Department of Anaesthesia and Intensive Care, University of Angers, CHU Angers, Angers, France.
¹³ Department of Intensive Care, Guadeloupe University Hospital, French Caribbean, France.
¹⁴ Department of Intensive Care, Fort-de-France Hospital, Martinique University Hospital, French Caribbean, France.
¹⁵ Department of Intensive Care, Nîmes University Hospital, Nîmes, France.
¹⁶ Department of Anaesthesiology and Critical Care, Sorbonne University, Saint-Antoine Hospital, Paris, France.
¹⁷ Department of Medical Intensive Care, CHU Grenoble-Alpes, Grenoble, France.
¹⁸ Department of Anaesthesia and Intensive Care, Department A, Lapeyronie University Hospital, Montpellier, France.
¹⁹ Department of Intensive Care Medicine, University of Montpellier, CHU Montpellier, Montpellier, France.
²⁰ Department of Anaesthesia and Intensive Care, Beaujon Hospital, AP-HP, University Paris Cité, Paris, France.
²¹ Department of Anaesthesia and Intensive Care, University of Tours, CHU Tours, Tours, France; Department of Anaesthesia and Intensive Care, Beaujon Hospital, AP-HP, University Paris Cité, Paris, France.
²² Department of Anaesthesia and Intensive Care, University Hospital of Nancy, Nancy, France.
²³ Critical Care Unit, University Hospital of Purpan, Toulouse, France.
²⁴ Department of Anaesthesia and Critical Care, CHU Bordeaux, Magellan Medico-Surgical Centre, University of Bordeaux, Biology of Cardiovascular Diseases, Bordeaux and Pessac, France.
²⁵ Department of Intensive Care Medicine, CHU Gabriel-Montpied, Clermont-Ferrand, France.
²⁶ Pole Anesthésie Réanimation Hopital R Debré, CHU de Reims, Reims, France.
²⁷ Department of Anaesthesia and Intensive Care, Institut Paoli-Calmettes, Marseille, France.
²⁸ Department of Intensive Care Medicine, GRRROH Group, Saint-Louis Hospital, University of Paris, Paris, France.
²⁹ Department of Anaesthesia and Perioperative Medicine, Georges Pompidou European Hospital, AP-HP, University Paris Cité, Paris, France.
³⁰ Clinical Research Department, University Hospital of Montpellier, University of Montpellier, Montpellier, France.
³¹ IMAG Laboratory, CNRS, University of Montpellier, CHU Montpellier, Montpellier, France.
³² Department of Anaesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, Saint-Éloi Hospital, Montpellier, France. Electronic address: s-jaber@chu-montpellier.fr.

PMID: 41046173
PMCID: PMC12597368
DOI: 10.1016/j.bja.2025.09.002

Randomized Controlled Trial

Noninvasive ventilation in postoperative critically ill patients with morbid obesity: secondary analysis of the EXTUBOBESE multicentre randomised clinical trial

Audrey De Jong et al. Br J Anaesth. 2025 Nov.

. 2025 Nov;135(5):1477-1485.

doi: 10.1016/j.bja.2025.09.002. Epub 2025 Oct 3.

Authors

Collaborators

EXTUB-OBESE trial group:
Boris Jung, Claudine Gniadek, Aurélie Vonarb, Albert Prades, Carine Jaillet, Samir Jaber, Gérald Chanques, Fouad Belafia, Audrey De Jong, Séverin Ramin, Xavier Capdevila, Jonathan Charbit, François Stephan, Thibaut Genty, Saida Rezaiguia-Delclaux, Audrey Imbert, Catherine Pilorge, Calypso Roman, Astrid Bouteau-Durand, Amélie Rollé, Michel Carles, Pierre-Marie Fayolle, Hossen Mehdaoui, Juliette Sautillet, Bertrand Souweine, Laure Calvet, Claire Dupuis, Thomas Godet, Matthieu Jabaudon, Emmanuel Futier, Raiko Blondonnet, Benjamin Rieu, Nicolas Terzi, Clara Candille, Florian Sigaud, Béatrice Riu, Benjamine Sarton, Sigismond Lasocki, Laurent Papazian, Aude Sylvestre, Sabine Valera, Djamel Mokart, Laurent Chow Chine, Magali Bisbal, Camille Pouliquen, Jean-Manuel de Guibert, Maxime Tourret, Damien Mallet, Marc Léone, Laurent Zieleskiewicz, Virginie Lemiale, Elie Azoulay, Philippe Seguin, Yoann Launey, Jeanne Cossic, Joel Cousson, Mona Assefi, Elodie Baron, Lucie Collet, Cyril Quemeneur, Antoine Monsel, Jean-Michel Constantin, Matthieu Biais, Hadrien Rozé, Alexandre Ouattara, Eline Bonnardel, Simon Monziols, Martin Mahul, Laurent Muller, Jean-Yves Lefrant, Claire Roger, Saber Barbar, Martine Ferrandière, Fabien Lambiotte, Piehr Saint-Léger, Paer-Selim Abback, Catherine Paugam, Emmanuel Weiss, Julien Pottecher, Pierre-Olivier Ludes, Karim Asehnoune, Emmanuel Pardo, Lucie Darrivere, Marc Garnier, Anne Bignon, Eric Kipnis, Gilles Lebuffe, Matthias Garot, Jeremy Falcone, Benjamin Chousterman, Magali Collet, Etienne Gayat, Philippe Guerci, Jean Dellamonica, Willy-Serge Mfam, Bernard Cholley, Evelina Ochin, Mohamed Nebli, Nejla Tilouche, Benjamin Madeux, David Bougon, Yassir Aarab, Fanny Garnier

Affiliations

¹ Department of Anaesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, Saint-Éloi Hospital, Montpellier, France.
² Clinical Research and Epidemiology Unit, University of Montpellier, CHU Montpellier, Montpellier, France.
³ CHU Lille, Reanimation Chirurgical, Lille, France.
⁴ Surgical Intensive Care Unit, Marie Lannelongue Hospital, Saclay University, School of Medicine, Le Plessis-Robinson, France.
⁵ Department of Peri-Operative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France.
⁶ Department of Anaesthesiology and Critical Care, Sorbonne University, Pitié-Salpêtrière Hospital, Paris, France.
⁷ Department of Anaesthesia and Critical Care, Hôtel Dieu, University Hospital of Nantes, Nantes, France.
⁸ Assistance Publique - Hôpitaux de Marseille, Hôpital Nord, Department of Intensive Care Medicine, Aix-Marseille University, Faculty of Medicine, Centre d'Études et de Recherches sur les Services de Santé et Qualité de Vie, Marseille, France.
⁹ Department of Intensive Care, Papeete Hospital, Tahiti, French Polynesia.
¹⁰ Department of Anaesthesia and Intensive Care, University of Tours, CHU Tours, Tours, France.
¹¹ Department of Anaesthesia and Intensive Care, University of Rennes, CHU Rennes, Rennes, France.
¹² Department of Anaesthesia and Intensive Care, University of Angers, CHU Angers, Angers, France.
¹³ Department of Intensive Care, Guadeloupe University Hospital, French Caribbean, France.
¹⁴ Department of Intensive Care, Fort-de-France Hospital, Martinique University Hospital, French Caribbean, France.
¹⁵ Department of Intensive Care, Nîmes University Hospital, Nîmes, France.
¹⁶ Department of Anaesthesiology and Critical Care, Sorbonne University, Saint-Antoine Hospital, Paris, France.
¹⁷ Department of Medical Intensive Care, CHU Grenoble-Alpes, Grenoble, France.
¹⁸ Department of Anaesthesia and Intensive Care, Department A, Lapeyronie University Hospital, Montpellier, France.
¹⁹ Department of Intensive Care Medicine, University of Montpellier, CHU Montpellier, Montpellier, France.
²⁰ Department of Anaesthesia and Intensive Care, Beaujon Hospital, AP-HP, University Paris Cité, Paris, France.
²¹ Department of Anaesthesia and Intensive Care, University of Tours, CHU Tours, Tours, France; Department of Anaesthesia and Intensive Care, Beaujon Hospital, AP-HP, University Paris Cité, Paris, France.
²² Department of Anaesthesia and Intensive Care, University Hospital of Nancy, Nancy, France.
²³ Critical Care Unit, University Hospital of Purpan, Toulouse, France.
²⁴ Department of Anaesthesia and Critical Care, CHU Bordeaux, Magellan Medico-Surgical Centre, University of Bordeaux, Biology of Cardiovascular Diseases, Bordeaux and Pessac, France.
²⁵ Department of Intensive Care Medicine, CHU Gabriel-Montpied, Clermont-Ferrand, France.
²⁶ Pole Anesthésie Réanimation Hopital R Debré, CHU de Reims, Reims, France.
²⁷ Department of Anaesthesia and Intensive Care, Institut Paoli-Calmettes, Marseille, France.
²⁸ Department of Intensive Care Medicine, GRRROH Group, Saint-Louis Hospital, University of Paris, Paris, France.
²⁹ Department of Anaesthesia and Perioperative Medicine, Georges Pompidou European Hospital, AP-HP, University Paris Cité, Paris, France.
³⁰ Clinical Research Department, University Hospital of Montpellier, University of Montpellier, Montpellier, France.
³¹ IMAG Laboratory, CNRS, University of Montpellier, CHU Montpellier, Montpellier, France.
³² Department of Anaesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, Saint-Éloi Hospital, Montpellier, France. Electronic address: s-jaber@chu-montpellier.fr.

PMID: 41046173
PMCID: PMC12597368
DOI: 10.1016/j.bja.2025.09.002

Abstract

Background: The optimal method to prevent treatment failure after tracheal extubation in postoperative critically ill patients with obesity and morbid obesity remains unknown.

Methods: We conducted a secondary analysis of the EXTUBOBESE multicentre RCT comparing prophylactic noninvasive ventilation (NIV) and oxygen therapy (high-flow nasal oxygen [HFNO] and standard oxygen) in 585 postoperative critically ill patients with obesity (BMI ≥30 kg m^-2) and morbid obesity (BMI ≥40 kg m^-2). The primary outcome was treatment failure within 3 days after extubation, a composite of reintubation within 3 days (also analysed separately as secondary outcome), switch to the other study treatment, or premature study treatment discontinuation. The primary outcome analysis used a χ² test. A Cox model was used for time without reintubation.

Results: Treatment failure occurred in 39/292 patients (13.4%) in the NIV group and in 70/293 patients (23.9%) in the oxygen therapy group (absolute risk difference: -10.5; 95% confidence interval: -16.8 to -4.3). Similar results were found when analysing separately HFNO from standard oxygen in the oxygen therapy group. Reintubation rate was 8.6% (25 patients) in the NIV group and 9.9% (29 patients) in the oxygen therapy group (P=0.58). Interaction test was significant for level of obesity (P=0.045). Time without reintubation according to level of obesity significantly differed between NIV group and oxygen therapy group (P=0.02) in patients with BMI ≥40 kg m^-2, but not in patients with 30≤BMI<40 kg m^-2 (P=0.70).

Conclusions: Among postoperative critically ill adults with obesity undergoing tracheal extubation, our results suggest that use of noninvasive ventilation is effective to reduce treatment failure in comparison with oxygen therapy alone. These effects were more pronounced in patients with morbid obesity.

Clinical trial registration: NCT04014920.

Keywords: acute respiratory failure; extubation; intensive care unit; noninvasive ventilation; obesity; postoperative care; weaning.

PubMed Disclaimer

Conflict of interest statement

Declarations of interest SJ reports receiving consulting fees from Drager, Medtronic, Mindray, Fresenius, Baxter, and Fisher & Paykel. ADJ reports receiving remuneration for presentations from Medtronic, Drager, and Fisher & Paykel. VL reported being a member of a research group that has received grants from Alexion, Baxter, MSD, Gilead, Sanofi, and Celgène. NT received fees for lecture by Fisher & Paykel outside this work and is supported by Pfizer for attending meetings, travel, or both and non-financial supports from Gilead outside this work. No conflicts of interest are reported for other authors.

Figures

**Fig 1**
Subgroup analyses of the primary outcome. The method of oxygen delivery while on oxygen therapy (high-flow nasal oxygen vs standard oxygen) did not modify the effect of the noninvasive ventilation (NIV) group on the treatment failure rate. Length of mechanical ventilation, and age did not modify the effect of NIV group on the treatment failure rate, whereas level of obesity did (P for interaction: 0.045). CI, confidence interval.

**Fig 2**
Kaplan–Meier analysis of the primary outcome. Time without treatment failure within 3 days after extubation was significantly higher in the noninvasive ventilation group than in the oxygen therapy group.

**Fig 3**
Kaplan–Meier analysis of reintubation within 3 days according to level of obesity. Time without reintubation within 3 days according to the level of obesity significantly differed between the noninvasive ventilation (NIV) group and oxygen therapy group (P=0.02) in patients with BMI ≥40 kg m⁻², but not in patients with BMI between 30 and 40 kg m⁻² (P=0.70).

See this image and copyright information in PMC

References

1. Hernández G., Dianti J., Paredes I., et al. Humidified noninvasive ventilation versus high-flow therapy to prevent reintubation in patients with obesity: a randomized clinical trial. Am J Respir Crit Care Med. 2025;211:222–229. - PubMed
1. De Jong A., Wrigge H., Hedenstierna G., et al. How to ventilate obese patients in the ICU. Intensive Care Med. 2020;46:2423–2435. - PMC - PubMed
1. De Jong A., Rollé A., Souche F.R., et al. How can I manage anaesthesia in obese patients? Anaesth Crit Care Pain Med. 2020;39:229–238. - PubMed
1. Pickkers P. The obesity paradox in patients in need of extracorporeal membrane oxygenation. Am J Respir Crit Care Med. 2023;208:649–650. - PMC - PubMed
1. Althoff M.D., Gaietto K., Holguin F., Forno E. Obesity-related asthma: a pathobiology-based overview of existing and emerging treatment approaches. Am J Respir Crit Care Med. 2024;210:1186–1200. - PMC - PubMed

Publication types

Actions
Actions

MeSH terms

Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions

Associated data

Actions
- Search in PubMed
- Search in ClinicalTrials.gov

LinkOut - more resources

Full Text Sources
Medical
- ClinicalTrials.gov
- MedlinePlus Health Information

Save citation to file

Email citation

Add to Collections

Add to My Bibliography

Your saved search

Create a file for external citation management software

Your RSS Feed

Noninvasive ventilation in postoperative critically ill patients with morbid obesity: secondary analysis of the EXTUBOBESE multicentre randomised clinical trial

Collaborators

Affiliations

Noninvasive ventilation in postoperative critically ill patients with morbid obesity: secondary analysis of the EXTUBOBESE multicentre randomised clinical trial

Authors

Collaborators

Affiliations

Abstract

Conflict of interest statement

Figures

References

Publication types

MeSH terms

Associated data

LinkOut - more resources

Full Text Sources

Medical