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.

 

Does obesity impact on weaning from invasive ventilation: a secondary analysis of the WEAN SAFE study

Annals of Intensive Care volume 15, Article number: 164 (2025) Published: 21 October 2025

Objective

To understand the impact of obesity on outcomes of weaning from invasive mechanical ventilation (MV).

Methods

The study population consisted of patients enrolled in the WEAN SAFE study. We defined 4 groups based on body mass index (BMI), namely: Normal weight (BMI 18.5–24.9 kg/m²), Overweight (BMI 25–29.9 kg/m²), Obesity Class I (BMI 30–34.9 kg/m²), and obesity classes II and III (BMI ≥ 35 kg/m²). The primary outcome was the rate of successful extubation in patients in each BMI group. Secondary outcomes included the ICU and hospital survival, and PEEP levels at time of weaning eligibility in patients in each BMI group.

Results

In the study population, 1728 (38.2%) were of normal weight, 1395 (30.8%) were overweight, 590 (13.1%) were class I Obesity, and 431 (9.5%) were obesity classes II and III. Patients with obesity were more likely to be female, to be a medical admission, and to have comorbidities. Patients with grade II-III obesity had lower levels of sedation, later timing of the first separation attempt, longer time to weaning success, they received more noninvasive ventilation post extubation, and they had a longer ICU stay. In contrast, weaning success, and ICU and hospital mortality rates were not different in obese patients. There was no independent relationship between obesity and weaning delay, weaning success, or with overall survival outcomes. Higher PEEP at weaning eligibility was associated with weaning failure in normal and overweight patients but not in patients with obesity.

Conclusions

Patients with obesity had a more complex and longer weaning process, but obesity per se was not independently associated with adverse weaning outcomes.

 

 

 

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 frailty and older age on weaning from invasive ventilation: a secondary analysis of the WEAN SAFE study

Annals of Intensive Care volume 15, Article number: 13 (2025)

Published: 20 January 2025

Objective

To understand the impact of both frailty and chronologic age on outcomes of weaning from invasive mechanical ventilation (MV).

Methods

The study population consisted of patients enrolled in the ‘WorldwidE. AssessmeNt of Separation of pAtients From ventilatory assistancE (WEAN SAFE) study. We defined 4 non-overlapping groups, namely: ‘frail’ (clinical frailty scale [CFS] score > 4; age < 80 years); ‘elderly’ (CFS ≤ 4; age ≥ 80y), ‘frail \elderly’ (CFS > 4; age ≥ 80 years), and a ‘not frail or elderly’ population. The primary outcome was the impact of frailty and older age on delayed weaning and failed weaning from invasive MV. Secondary outcomes included the impact of frailty and age on ICU and hospital survival.

Results

In the study population, 760 (17%) were frail, while 360 (8%) were elderly, 197 (4%) were frail and elderly, while 3,176 (70%) were not frail or elderly. The frail and elderly cohorts were more likely to be female, had hypoxemic/hypercapnic respiratory failure or sepsis, and had more comorbidities. The proportion of delayed weaning and of failed weaning from invasive MV was significantly higher in the frail (28 and 23%), the elderly (25 and 19%), and the frail and elderly groups (22% and 25%), compared to the not frail or elderly population (12% and 13%, P < 0.01). ICU and hospital mortality was higher in the frail (21 and 33%), the elderly (19 and 31%), and the frail and elderly groups (26 and 46%), compared to the not frail or elderly population (12% and 18%, P < 0.001). In multivariate analyses, there was an independent association between frailty and delayed weaning initiation and weaning failure. Old age was independently associated with risk of weaning failure.

Conclusions

Frailty status had a more consistent impact than older age on weaning outcomes. However, overall outcomes in these cohorts are encouraging once separation attempts have been initiated.

 

 

 

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.

 

Effect of high-flow oxygen versus T-piece ventilation strategies during spontaneous breathing trials on weaning failure among patients receiving mechanical ventilation: a randomized controlled trial

by Hong Yeul Lee, Jinwoo Lee and Sang-Min Lee 

 

Critical Care volume 26, Article number: 402 (2022)

 

Background

A spontaneous breathing trial (SBT) is used to determine whether patients are ready for extubation, but the best method for choosing the SBT strategy remains controversial. We investigated the effect of high-flow oxygen versus T-piece ventilation strategies during SBT on rates of weaning failure among patients receiving mechanical ventilation.

Methods

This randomized clinical trial was conducted from June 2019 through January 2022 among patients receiving mechanical ventilation for ≥ 12 h who fulfilled the weaning readiness criteria at a single-center medical intensive care unit. Patients were randomized to undergo either T-piece SBT or high-flow oxygen SBT. The primary outcome was weaning failure on day 2, and the secondary outcomes were weaning failure on day 7, ICU and hospital length of stay, and ICU and in-hospital morality.

Results

Of 108 patients (mean age, 67.0 ± 11.1 years; 64.8% men), 54 received T-piece SBT and 54 received high-flow oxygen SBT. Weaning failure on day 2 occurred in 5 patients (9.3%) in the T-piece group and 3 patients (5.6%) in the high-flow group (difference, 3.7% [95% CI, − 6.1–13.6]; p = 0.713). Weaning failure on day 7 occurred in 13 patients (24.1%) in the T-piece group and 7 patients (13.0%) in the high-flow group (difference, 11.1% [95% CI, − 3.4–25.6]; p = 0.215). A post hoc subgroup analysis showed that high-flow oxygen SBT was significantly associated with a lower rate of weaning failure on day 7 (OR, 0.17 [95% CI, 0.04–0.78]) among those patients intubated because of respiratory failure (p for interaction = 0.020). The ICU and hospital length of stay and mortality rates did not differ significantly between the two groups. During the study, no serious adverse events were recorded.

Conclusions

Among patients receiving mechanical ventilation, high-flow oxygen SBT did not significantly reduce the risk of weaning failure compared with T-piece SBT. However, the study may have been underpowered to detect a clinically important treatment effect for the comparison of high-flow oxygen SBT versus T-piece SBT, and a higher percentage of patients with simple weaning and a lower weaning failure rate than expected should be considered when interpreting the findings.

Abdominal functional electrical stimulation to assist ventilator weaning in critical illness: a double-blinded, randomised, sham-controlled pilot study

Abdominal functional electrical stimulation to assist ventilator weaning in critical illness: a double-blinded, randomised, sham-controlled pilot study

by Euan J. McCaughey, Annemijn H. Jonkman, Claire L. Boswell-Ruys, Rachel A. McBain, Elizabeth A. Bye, Anna L. Hudson, David W. Collins, Leo M. A. Heunks, Angus J. McLachlan, Simon C. Gandevia and Jane E. Butler

Critical Care:  volume 23, Article number: 261 (2019)

Background:

For every day a person is dependent on mechanical ventilation, respiratory and cardiac complications increase, quality of life decreases and costs increase by > $USD 1500. Interventions that improve respiratory muscle function during mechanical ventilation can reduce ventilation duration. The aim of this pilot study was to assess the feasibility of employing an abdominal functional electrical stimulation (abdominal FES) training program with critically ill mechanically ventilated patients. We also investigated the effect of abdominal FES on respiratory muscle atrophy, mechanical ventilation duration and intensive care unit (ICU) length of stay.

Methods:

Twenty critically ill mechanically ventilated participants were recruited over a 6-month period from one metropolitan teaching hospital. They were randomly assigned to receive active or sham (control) abdominal FES for 30 min, twice per day, 5 days per week, until ICU discharge. Feasibility was assessed through participant compliance to stimulation sessions. Abdominal and diaphragm muscle thickness were measured using ultrasound 3 times in the first week, and weekly thereafter by a blinded assessor. Respiratory function was recorded when the participant could first breathe independently and at ICU discharge, with ventilation duration and ICU length of stay also recorded at ICU discharge by a blinded assessor.

Results:

Fourteen of 20 participants survived to ICU discharge (8, intervention; 6, control). One control was transferred before extubation, while one withdrew consent and one was withdrawn for staff safety after extubation. Median compliance to stimulation sessions was 92.1% (IQR 5.77%) in the intervention group, and 97.2% (IQR 7.40%) in the control group (p = 0.384). While this pilot study is not adequately powered to make an accurate statistical conclusion, there appeared to be no between-group thickness changes of the rectus abdominis (p = 0.099 at day 3), diaphragm (p = 0.652 at day 3) or combined lateral abdominal muscles (p = 0.074 at day 3). However, ICU length of stay (p = 0.011) and ventilation duration (p = 0.039) appeared to be shorter in the intervention compared to the control group.

Conclusions:

Our compliance rates demonstrate the feasibility of using abdominal FES with critically ill mechanically ventilated patients. While abdominal FES did not lead to differences in abdominal muscle or diaphragm thickness, it may be an effective method to reduce ventilation duration and ICU length of stay in this patient group. A fully powered study into this effect is warranted.

Trial registration:

The Australian New Zealand Clinical Trials Registry, ACTRN12617001180303. Registered 9 August 2017.

Frequency of Screening for Weaning From Mechanical Ventilation: Two Contemporaneous Proof-of-Principle Randomized Controlled Trials*

Frequency of Screening for Weaning From Mechanical Ventilation: Two Contemporaneous Proof-of-Principle Randomized Controlled Trials*

Critical Care Medicine: June 2019 - Volume 47 - Issue 6 - p 817–825

Objectives: It is unknown whether more frequent screening of invasively ventilated patients, identifies patients earlier for a spontaneous breathing trial, and shortens the duration of ventilation. We assessed the feasibility of conducting a large trial to evaluate screening frequency in critically ill adults in the North American context.

Design: We conducted two contemporaneous, multicenter, pilot, randomized controlled trials (the Liberation from Mechanical Ventilation and Screening Frequency [RELEASE] and Screening Elderly Patients For Inclusion in a Weaning [SENIOR] trials) to address concerns regarding the potential for higher enrollment, fewer adverse events, and better outcomes in younger patients.

Setting: Ten and 11 ICUs in Canada, respectively.

Patients: Parallel trials of younger (RELEASE < 65 yr) and older (SENIOR ≥ 65 yr) critically ill adults invasively ventilated for at least 24 hours. Interventions: Each trial compared once daily screening to “at least twice daily” screening led by respiratory therapists.

Measurements and Main Results: In both trials, we evaluated recruitment (aim: 1–2 patients/month/ICU) and consent rates, reasons for trial exclusion, protocol adherence (target: ≥ 80%), crossovers (aim: ≤ 10%), and the effect of the alternative screening frequencies on adverse events and clinical outcomes. We included 155 patients (53 patients [23 once daily, 30 at least twice daily] in RELEASE and 102 patients [54 once daily, 48 at least twice daily] in SENIOR). Between trials, we found similar recruitment rates (1.32 and 1.26 patients/month/ICU) and reasons for trial exclusion, high consent and protocol adherence rates (> 92%), infrequent crossovers, and few adverse events. Although underpowered, at least twice daily screening was associated with a nonsignificantly faster time to successful extubation and more successful extubations but significantly increased use of noninvasive ventilation in both trials combined.

Conclusions: Similar recruitment and consent rates, few adverse events, and comparable outcomes in younger and older patients support conduct of a single large trial in North American ICUs assessing the net clinical benefits associated with more frequent screening.

Person-centred care during prolonged weaning from mechanical ventilation, nurses’ views: an interview study

Person-centred care during prolonged weaning from mechanical ventilation, nurses’ views: an interview study

1 Intensive and Critical Care Nursing by Carl-Johan Cederwall, Sepideh Olausson, Louise Rose, Silvana Naredi, Mona Ringdal 

Abstract

Objective

To determine: 1) if the three elements of person-centred care (initiating, working and safeguarding the partnership) were present, and 2) to identify evidence of barriers to person-centred care during prolonged weaning from mechanical ventilation.

Research methodology

Secondary analysis of semi structured interviews with 19 critical care nurses using theoretical thematic analysis.

Setting

This study was conducted in three Swedish intensive care units, one in a regional hospital and two in a university hospital.

Findings

Three themes and nine subthemes related to person-centred care were identified. The three themes included: 1) ‘finding a person behind the patient’ related to the ‘initiating the partnership’ phase, 2) ‘striving to restore patient́s sense of control’ related to ‘working the partnership’ phase and 3) ‘impact of patient involvement’ related to ‘safeguarding the partnership’ phase of person-centred care’. Additionally a further theme ‘barriers to person-centred care’ was identified.

Conclusion

We found evidence of all three person-centred care routines. Barriers to person-centred care comprised of lack team collaboration and resources. Facilitating patients to actively participate in decision-making during the weaning process may optimise weaning outcomes and warrants further research.

Continuous care and patients’ basic needs during weaning from mechanical ventilation: A qualitative study

Continuous care and patients’ basic needs during weaning from mechanical ventilation: A qualitative study
Intensive and Critical Care Nursing
Khalafi Ali et al

Mechanical ventilation is associated with a number of risks and complications. Thus, rapid and safe weaning from mechanical ventilation is of great importance. Weaning is a complex and challenging process, requiring continuous care and knowledge of the patient.
The aim of the present study was to describe the continuous care process during weaning as well as to analyse the facilitators and obstacles to the weaning process from start to finish from the perspective of intensive care unit (ICU) staff, particularly nurses.

A Pilot Randomized Trial Comparing Weaning From Mechanical Ventilation on Pressure Support Versus Proportional Assist Ventilation

A Pilot Randomized Trial Comparing Weaning From MechanicalVentilation on Pressure Support Versus Proportional Assist Ventilation

Critical Care Medicine: June 2016 - Volume 44 - Issue 6 - p 1098–1108

Bosma, K et al

 

Objectives: Despite protocols incorporating spontaneous breathing trials, 31% of ICU patients experience difficult or prolonged weaning from mechanical ventilation. Nonfatiguing modes such as pressure support ventilation are recommended. Proportional assist ventilation provides assistance in proportion to patient effort, which may optimize weaning. However, it is not known how proportional assist ventilation performs relative to pressure support ventilation over a prolonged period in the complex ICU setting. The purpose of this study was to compare the physiologic and clinical performance (failure rate), safety, and feasibility of protocols using daily spontaneous breathing trial plus pressure support ventilation versus proportional assist ventilation until ventilation discontinuation. Design: Single-center, unblinded pilot randomized controlled trial. Setting: Medical-surgical ICU of a tertiary-care hospital. Patients: Adult patients intubated greater than 36 hours were randomized if they met eligibility criteria for partial ventilatory support, tolerated pressure support ventilation greater than or equal to 30 minutes, and either failed or did not meet criteria for a spontaneous breathing trial. Interventions: Patients were randomized to the pressure support ventilation or proportional assist ventilation protocol (PAV+, Puritan Bennett 840; Covidien, Boulder, CO). Both protocols used progressive decreases in level of assistance as tolerated, coupled with daily assessment for spontaneous breathing trials. Measurements and Main Results: Of 54 patients randomized, outcome data are available for 50 patients; 27 were randomized to receive proportional assist ventilation and 23 to receive pressure support ventilation. There were no adverse events linked to the study interventions, and protocol violations were infrequent. Recruitment was slower than projected (1.3 patients per month). The median (interquartile range) time from randomization to successful extubation was 3.9 days (2.8–8.4 d) on proportional assist ventilation versus 4.9 days (2.9–26.3 d) on pressure support ventilation (p = 0.39). Time to live ICU discharge was 7.3 days (5.2–11.4 d) on proportional assist ventilation versus 12.4 days (7.5–30.8 d) on pressure support ventilation (p = 0.03). Conclusion: This pilot study demonstrates the utility, safety, and feasibility of the weaning protocols and provides important information to guide the design of a future randomized controlled trial comparing weaning from mechanical ventilation on pressure support ventilation versus proportional assist ventilation.