With the ongoing COVID-19 pandemic, we’re paying a lot of attention to ventilators as tools to help critically ill patients. Eventually those patients are being extubated and it’s well-known that failed extubation is associated with an increased risk of mortality and morbidity. So, what tools are helping those patients through post-extubation?
Using High Flow Nasal Cannula (HFNC)
Traditionally, low flow oxygen therapy and noninvasive positive pressure ventilation (NiPPV) have been the devices to help support patients through post-extubation. In recent years, high flow nasal cannula (HFNC) has become a more widely accepted tool for this procedure. Studies by Hernandez and colleagues show that HFNC is superior to conventional oxygen therapy at preventing reintubation and similar in efficacy to NiPPV for reintubation prevention as well. Furthermore, Stephan and colleagues found that in cardiothoracic surgery patients, HFNC has similar efficacy to NiPPV in preventing or resolving acute respiratory distress during post-extubation.
However, it’s important to note that these studies exclude hypercapnic patients and are solely focused on hypoxemic patients. Although HFNC has attractive advantages over NiPPV—such as a more comfortable interface that allows patients to talk, eat, and take oral medication — it does have limitations when managing hypercapnic patients. This is why some clinicians implement HFNC in concert with NiPPV.
Using a Combination of HFNC and NiPPV
Thille and colleagues recently published a study in JAMA, titled “Effect of Postextubation High-Flow Nasal Oxygen With Noninvasive Ventilation vs High-Flow Nasal Oxygen Alone on Reintubation Among Patients at High Risk of Extubation Failure: A Randomized Clinical Trial.” This trial found that when both HFNC and NiPPV were used on patients of high risk of extubation failure, the risk of reintubation was significantly decreased when compared to use of HFNC alone.
In the discussion, the authors note that “noninvasive ventilation [NIV] may be beneficial on outcomes of hypercapnic patients …” They also note that “patients older than 65 years or with underlying chronic cardiac or respiratory disease are also at high risk of reintubation and could benefit from noninvasive ventilation.” This interpretation is in line with our understanding that hypercapnia is a symptom that leads to increased work of breathing that calls for ventilatory support intervention.
Using High Velocity Therapy
Given the chances of extubation success by using a combination of NIV and HFNC, clinicians should be aware of Vapotherm high velocity therapy as a post-extubation support tool. High velocity therapy is a mask-free form of NIV that offers ventilatory support, but is very similar to HFNC when it comes to patient comfort.
Using a small-bore nasal cannula to deliver high velocity, conditioned gas to the patient, high velocity therapy achieves comparable efficacy to NiPPV on hypercapnic as well as hypoxemic patients, but without a mask. Furthermore, a subgroup analysis suggests that high velocity therapy may be a viable alternative to NiPPV in treating patients with respiratory distress secondary to Acute Decompensated Heart Failure.
It is a tool that combines the efficacy of NiPPV with the comfort of HFNC. Your patients can talk without a pressure-based mask muffling their speech. They also receive optimally conditioned gas that ensures airway health and function. This comfortable yet efficacious therapy could be an attractive option for post-extubation respiratory support, whether for COVID-19 patients or others.
No Mask. No Problem. Mask-Free NIV
 Epstein SK et al, Effects of Failed Extubation on Outcome of Mechanical Ventilation. CHEST. 1997; 112(1); 186-192.
 Hernandez et al, Effect of Postextubation High-Flow Nasal Cannula vs Conventional Oxygen Therapy on Reintubation in Low-Risk Patients: A Randomized Control Trial. JAMA. 2016; 315(113);1354-1361.
 Hernandez et al, Effects of Postextubation High-Flow Nasal Cannula Cannula vs Noninvasive Ventilation on Reintubation and Postextubation Respiratory Failure in High Risk Patients; A Randomized Controlled Trial. JAMA. 2016; 316(15):1565-1574.
 Stephan et al, High-Flow Nasal Oxygen vs Noninvasive Positive Airway Pressure in Hypoxemic Patients After Cardiothoracic Surgery: A Randomized Clinical Trial. 2015; 313(23): 2331-2339.
 Thille, A.W. et al. Effect of Postextubation High-Flow Nasal Oxygen With Noninvasive Ventilation vs High-Flow Nasal Oxygen Alone on Reintubation Among Patients at High Risk of Extubation Failure: A Randomized Clinical Trial. JAMA. 2019 Oct 2;322(15):1465-1475. doi: 10.1001/jama.2019.14901.
 Doshi P, Whittle JS, Bublewicz M, et al. High-Velocity Nasal Insufflation in the Treatment of Respiratory Failure: A Randomized Clinical Trial. Ann Emerg Med 2018;72:73-83 e5.
 Haywood, Steven T, Jessica S. Whittle, Leonithas I. Volakis, George Dungan II, Michael Bublewicz, Joseph Kearney, Terrell Ashe, Thomas L. Miller, Pratik Doshi. “HVNI vs NIPPV in the treatment of acute decompensated heart failure: Subgroup analysis of a multi-center trial in the ED.” The American Journal of Emergency Medicine, 2019. https://doi.org/10.1016/j.ajem.2019.03.002