Post-extubation non-invasive ventilation: for which patients?

Abstract

Non-invasive ventilation (NIV) is widely used for the treatment of acute respiratory failure in the intensive care unit and has been therefore naturally used to hasten extubation and avoid reintubation. In the post-extubation period, three different situations should be clearly distinguished: 1) The first situation is the use of NIV to hasten extubation in difficult-to-wean patients. Despite the failure of a weaning trial, the patient is extubated and treated by intensive NIV after extubation. This strategy can be discussed for some patients with chronic respiratory failure but cannot be routinely proposed as reference method in clinical practice. 2) The second situation is the use of prophylactic NIV immediately applied after planned extubation, i.e. before the occurrence of a respiratory distress in patients ready for extubation. This strategy should be systematically used in order to prevent post-extubation acute respiratory failure in hypercapnic patients with any underlying chronic lung disease. Further studies are needed to expand its use in other patients considered at high risk for extubation failure. 3) The third situation is the use of therapeutic NIV to treat patients who have already signs of respiratory distress. This strategy can be dangerous and should not be used in clinical practice, except in postoperative patients after thoracic surgery or in patients with chronic lung disease. Clinical trials on weaning are difficult because of the low number of reintubated patients. However, despite the absence of current recommendations, the literature enables to justify some propositions.