Using HFNC to increase the success of extubation

Despite the benefits of high-flow nasal cannula (HFNC) in reducing the need for intubation in patients with moderate and severe lung injury, 30% of patients may end up requiring intubation and mechanical ventilation. Since high-flow nasal cannula can improve oxygen delivery, wash out upper airway dead space, and improve the functional residual capacity, let’s evaluate HFNC for respiratory support after extubation.

Consider a patient with pneumonia. Despite antibiotics and the use of high flow oxygen for hypoxia, the patient worsens and requires mechanical ventilation. After five days of excellent intensive care unit (ICU) care, the patient is passing a spontaneous breathing trial (SBT) and ready for extubation.

Traditionally, patients would be extubated to a traditional nasal cannula. Noninvasive ventilation (NIV) would be used for patients with continued hypercapnia during the breathing trial or those considered high-risk for extubation failure.

HFNC has been found to reduce the need for reintubation after liberation from mechanical ventilation. HFNC has been evaluated in patients with both a low-risk for reintubation and a high-risk for reintubation.

HFNC use in patients at low-risk for reintubation

Patients who are low-risk for reintubation are generally young, have few comorbidities, were not intubated very long and passed their first attempted SBT. These are patients that most clinicians would predict would do very well after extubation.

Remarkably, the use of high-flow nasal cannula in this low-risk cohort reduced the risk of reintubation by 7% when compared to conventional oxygen given by nasal cannula or face mask.

HFNC use in patients at high-risk for reintubation

But, what role can HFNC play in patients at high-risk for reintubation?

Patients without the low-risk features previously discussed—those that are older, were intubated longer, had congestive heart failure or chronic obstructive pulmonary disease (COPD), and were hypercapnic—were studied to determine the need for reintubation.

In the high-risk cohort, there was no statistical difference in failure when extubating to the HFNC compared to NIV mask, suggesting that HFNC is equally as effective in patients at highest risk for reintubation.

So, high-flow nasal cannula, or HFNC, can reduce the risk of reintubation in low or high-risk patients by a value greater than or equal to that of conventional approaches.

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