Respiratory support (non-invasive ventilation or high flow nasal cannula) applied at the time of extubation has been reported to reduce reintubation rates, but concerns regarding effectiveness have limited uptake into practice.
To determine if providing post-extubation respiratory support to all patients undergoing extubation in a medical ICU would decrease the incidence of reintubation.
We conducted a pragmatic, two-armed, cluster-crossover trial of adults undergoing extubation from invasive mechanical ventilation between October 1, 2017 and March 31, 2019 in the medical intensive care unit of an academic medical center. Patients were assigned to either protocolized post-extubation respiratory support (a respiratory therapist-driven protocol in which patients with suspected hypercapnia received non-invasive ventilation and patients without suspected hypercapnia received high flow nasal cannula) or usual care (post-extubation management at the discretion of treating clinicians). The primary outcome was reintubation within 96 hours of extubation.
A total of 751 patients were enrolled. Of the 359 patients assigned to protocolized support, 331 (92.2%) received post-extubation respiratory support, compared to 66 of 392 patients (16.8%) assigned to usual care, a difference driven by differential use of high flow nasal cannula (74.7% vs. 2.8%). A total of 57 patients (15.9%) in the protocolized support group experienced reintubation, compared to 52 patients (13.3%) in the usual care group (odds ratio, 1.23; 95% confidence interval, 0.82 to 1.84; P-value = 0.32).
Among a broad population of critically ill adults undergoing extubation from invasive mechanical ventilation at an academic medical center, protocolized post-extubation respiratory support, primarily characterized by an increase in the use of high flow nasal cannula, did not prevent reintubation, compared to usual care. Clinical trial registration available at, ID: NCT03288311.