High-flow nasal cannula oxygen during breaks from noninvasive ventilation after extubation: an observational study

Intensive Care Medicine: Published: 13 July 2026

Abstract

Purpose

Clinical practice guidelines recommend prophylactic noninvasive ventilation (NIV) after extubation in high-risk patients. The effects of high-flow nasal cannula (HFNC) oxygen during breaks from NIV after extubation have been poorly explored. Our objective was to assess whether HFNC rather than standard oxygen during breaks from NIV may prevent extubation failure.

Methods

Observational study based on two multicenter clinical trials including patients at high-risk of extubation failure (> 65 years or with underlying cardiac or respiratory disease). We included the 1077 patients who received prophylactic NIV after extubation, alternating with HFNC (NIV/HFNC) or standard oxygen (NIV/O₂). The primary outcome was the proportion of patients who failed extubation (reintubation or death within the seven days following extubation). We used G-computation to estimate the causal effect of HFNC on the risk of extubation failure, while accounting for confounding factors.

Results

After extubation, 655 patients (61%) received NIV/HFNC while 422 (39%) received NIV/O₂. The extubation failure rate at day 7 was significantly lower with NIV/HFNC than with NIV/O₂ (13.7% vs. 18.5%; difference, − 4.7% [95% CI, − 9.4% to – 0.3%]; p = 0.036). Using G-computation, NIV/HFNC was not more effective than NIV/O₂ in reducing the risk of extubation failure, with an estimated adjusted difference of − 3.9% [95% CI, − 8.7% to 0.9%]. Reintubation rates were significantly lower with NIV/HFNC than with NIV/O₂ at 48h, but did not significantly differ beyond 48h.

Conclusions

Although the adjusted analysis did not confirm the favorable unadjusted findings, HFNC during breaks from NIV might decrease the risk of extubation failure, and warrants future clinical trials.

 

Handgrip strength association with weaning outcome in mechanically ventilated ICU patients: a systematic review and meta-analysis

Critical Care volume 29, Article number: 478 (2025) Published: 07 November 2025

Abstract

Weaning from mechanical ventilation is a critical process in the intensive care unit (ICU), and extubation failure remains associated with poor outcomes. ICU-acquired weakness has been identified as a risk factor for delayed weaning. Maximal handgrip strength (HGS) is a simple bedside measure proposed as a surrogate marker of global muscle strength. This systematic review and meta-analysis aimed to assess the association between HGS and weaning outcomes in ICU patients. A systematic search of MEDLINE, EMBASE, CINAHL, and Cochrane Library was conducted up to December 2024. We included prospective cohort studies assessing maximal HGS prior to extubation in mechanically ventilated adults, and its association with extubation failure, spontaneous breathing trial (SBT) failure, or weaning classification (simple, difficult, or prolonged). Meta-analyses pooled mean differences in HGS between outcome groups, and diagnostic accuracy was evaluated using a hierarchical summary ROC model. Risk of bias was assessed using the QUIPS tool. Seven studies were included in the review (n = 707 patients), and six in the meta-analysis. No significant difference in HGS was found between extubation failure and success (mean difference: − 3.62 kg; 95% CI: − 7.92 to 0.62). However, significantly lower HGS was associated with SBT failure (–3.00 kg; 95% CI: − 4.64 to − 1.36) and non-simple weaning (–3.94 kg; 95% CI: − 5.31 to − 2.58). Pooled sensitivity and specificity of HGS were 72% and 60% respectively, in predicting either extubation failure or non-simple weaning. Negative predictive values ranged from 90% to 95%, for 10% and 20% pre-test probability. Maximal HGS does not appear to significantly differentiate extubation success from failure Given the limited number of studies and their heterogeneity, further high-quality research is needed to clarify its prognostic value across different patient subgroups and timeframes.

 

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

Critical Care volume 29, Article number: 185 Published: 08 May 2025

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 (sPTP_es 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 (sPTP_es 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.

 

 

Impact of sleep disturbances on outcomes in intensive care units

Critical Care volume 28, Article number: 331, Published: 09 October 2024

Background

Sleep deprivation is common in intensive care units (ICUs) and may alter respiratory performance. Few studies have assessed the role of sleep disturbances on outcomes in critically ill patients.

Objectives

We hypothesized that sleep disturbances may be associated with poor outcomes in ICUs.

Methods

Post-hoc analysis pooling three observational studies assessing sleep by complete polysomnography in 131 conscious and non-sedated patients included at different times of their ICU stay. Sleep was assessed early in a group of patients admitted for acute respiratory failure while breathing spontaneously (n = 34), or under mechanical ventilation in patients with weaning difficulties (n = 45), or immediately after extubation (n = 52). Patients admitted for acute respiratory failure who required intubation, those under mechanical ventilation who had prolonged weaning, and those who required reintubation after extubation were considered as having poor clinical outcomes. Durations of deep sleep, rapid eye movement (REM) sleep, and atypical sleep were compared according to the timing of polysomnography and the clinical outcomes.

Results

Whereas deep sleep remained preserved in patients admitted for acute respiratory failure, it was markedly reduced under mechanical ventilation and after extubation (p < 0.01). Atypical sleep was significantly more frequent in patients under mechanical ventilation than in those breathing spontaneously (p < 0.01). REM sleep was uncommon at any time of their ICU stay. Patients with complete disappearance of REM sleep (50% of patients) were more likely to have poor clinical outcomes than those with persistent REM sleep (24% vs. 9%, p = 0.03).

Conclusion

Complete disappearance of REM sleep was significantly associated with poor clinical outcomes in critically ill patients.

 

Effectiveness of diaphragmatic ultrasound as a predictor of successful weaning from mechanical ventilation: a systematic review and meta-analysis

 

by Henry M. Parada-Gereda, Adriana L. Tibaduiza, Alejandro Rico-Mendoza, Daniel Molano-Franco, Victor H. Nieto, Wanderley A. Arias-Ortiz, Purificación Perez-Terán and Joan R. Masclans 

 

Critical Care volume 27, Article number: 174 (2023) 

 

Background

Several measurements have been used to predict the success of weaning from mechanical ventilation; however, their efficacy varies in different studies. In recent years, diaphragmatic ultrasound has been used for this purpose. We conducted a systematic review and meta-analysis to evaluate the effectiveness of diaphragmatic ultrasound in predicting the success of weaning from mechanical ventilation.

Methods

Two investigators independently searched PUBMED, TRIP, EMBASE, COCHRANE, SCIENCE DIRECT, and LILACS for articles published between January 2016 and July 2022. The methodological quality of the studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool; additionally, the certainty of the evidence is evaluated using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methodology. Sensitivity and specificity analysis was performed for diaphragmatic excursion and diaphragmatic thickening fraction; positive and negative likelihood ratios and diagnostic odds ratios (DOR) with their confidence intervals (95% CI) were calculated by random effects analysis, summary receiver operating characteristic curve was estimated. Sources of heterogeneity were explored by subgroup analysis and bivariate meta-regression.

Results

Twenty-six studies were included, of which 19 were included in the meta-analysis (1204 patients). For diaphragmatic excursion, sensitivity was 0.80 (95% CI 0.77–0.83), specificity 0.80 (95% CI 0.75–0.84), area under the summary receiver operating characteristic curve 0.87 and DOR 17.1 (95% CI 10.2–28.6). For the thickening fraction, sensitivity was 0.85 (95% CI 0.82–0.87), specificity 0.75 (95% CI 0.69–0.80), area under the summary receiver operating characteristic curve 0.87 and DOR 17.2 (95% CI 9.16–32.3). There was heterogeneity among the included studies. When performing a subgroup analysis and excluding studies with atypical cutoff values, sensitivity and specificity increased for diaphragmatic thickening fraction; sensitivity increased and specificity decreased for diaphragmatic excursion; when comparing studies using pressure support (PS) versus T-tube, there was no significant difference in sensitivity and specificity; bivariate meta-regression analysis shows that patient position at the time of testing was a factor of heterogeneity in the included studies.

Conclusions

Measurement of diaphragmatic excursion and diaphragmatic thickening fraction predict the probability of successful weaning from mechanical ventilation with satisfactory diagnostic accuracy; however, significant heterogeneity was evident in the different included studies. Studies of high methodological quality in specific subgroups of patients in intensive care units are needed to evaluate the role of diaphragmatic ultrasound as a predictor of weaning from mechanical ventilation.