法国普瓦提埃重症急救医学中心Arnaud W. Thille小组的一项最新研究，分析了拔管后无创通气联合高流量鼻腔给氧与单独高流量鼻腔给氧，对拔管失败高危患者再插管的影响。该研究2019年10月15日发表于《美国医学会杂志》。

在重症监护病房（ICU）中，高流量鼻腔给氧可预防拔管后呼吸衰竭，高流量鼻腔给氧联合无创机械通气（NIV）可能是避免再次插管的最佳通气策略。

2017年4月到2018年1月，研究组在法国30个ICU对641名拔管失败高风险（65岁以上、潜在心脏或呼吸系统疾病）的患者进行了一项多中心的随机临床试验，当他们拔管后，立即随机分组，306例接受高流量鼻腔给氧，342例接受高流量鼻腔给氧联合NIV。随访至2018年3月。

高流量鼻氧+NIV组的第7天再插管率为11.8%，第7天呼吸衰竭发生率为21%，直到ICU出院的再插管率为12%，均显著低于单独高流量鼻氧组（18.2%、29%和20%）。高流量鼻氧+NIV组的ICU死亡率为6%，单独高流量鼻氧组为9%，差异不显著。

总之，对于拔管失败高风险的机械通气患者，拔管后立即应用高流量鼻腔给氧联合NIV，与单用高流量鼻腔给氧相比，显著降低了再插管的风险。

附：英文原文

Title: 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

Author: Arnaud W. Thille, Grégoire Muller, Arnaud Gacouin, Rémi Coudroy, Maxens Decavèle, Romain Sonneville, Franois Beloncle, Christophe Girault, Laurence Dangers, Alexandre Lautrette, Séverin Cabasson, Anahita Rouzé, Emmanuel Vivier, Anthony Le Meur, Jean-Damien Ricard, Keyvan Razazi, Guillaume Barberet, Christine Lebert, Stephan Ehrmann, Caroline Sabatier, Jeremy Bourenne, Gael Pradel, Pierre Bailly, Nicolas Terzi, Jean Dellamonica, Guillaume Lacave, Pierre-éric Danin, Hodanou Nanadoumgar, Aude Gibelin, Lassane Zanre, Nicolas Deye, Alexandre Demoule, Adel Maamar, Mai-Anh Nay, René Robert, Stéphanie Ragot, Jean-Pierre Frat

Issue&Volume: 2019/10/15

Abstract: 

Importance  High-flow nasal oxygen may prevent postextubation respiratory failure in the intensive care unit (ICU). The combination of high-flow nasal oxygen with noninvasive ventilation (NIV) may be an optimal strategy of ventilation to avoid reintubation.

Objective  To determine whether high-flow nasal oxygen with prophylactic NIV applied immediately after extubation could reduce the rate of reintubation, compared with high-flow nasal oxygen alone, in patients at high risk of extubation failure in the ICU.

Design, Setting, and Participants  Multicenter randomized clinical trial conducted from April 2017 to January 2018 among 641 patients at high risk of extubation failure (ie, older than 65 years or with an underlying cardiac or respiratory disease) at 30 ICUs in France; follow-up was until April 2018.

Interventions  Patients were randomly assigned to high-flow nasal oxygen alone (n = 306) or high-flow nasal oxygen with NIV (n = 342) immediately after extubation.

Main Outcomes and Measures  The primary outcome was the proportion of patients reintubated at day 7; secondary outcomes included postextubation respiratory failure at day 7, reintubation rates up until ICU discharge, and ICU mortality.

Results  Among 648 patients who were randomized (mean [SD] age, 70 [10] years; 219 women [34%]), 641 patients completed the trial. The reintubation rate at day 7 was 11.8% (95% CI, 8.4%-15.2%) (40/339) with high-flow nasal oxygen and NIV and 18.2% (95% CI, 13.9%-22.6%) (55/302) with high-flow nasal oxygen alone (difference, −6.4% [95% CI, −12.0% to −0.9%]; P = .02). Among the 11 prespecified secondary outcomes, 6 showed no significant difference. The proportion of patients with postextubation respiratory failure at day 7 (21% vs 29%; difference, −8.7% [95% CI, −15.2% to −1.8%]; P = .01) and reintubation rates up until ICU discharge (12% vs 20%, difference −7.4% [95% CI, −13.2% to −1.8%]; P = .009) were significantly lower with high-flow nasal oxygen and NIV than with high-flow nasal oxygen alone. ICU mortality rates were not significantly different: 6% with high-flow nasal oxygen and NIV and 9% with high-flow nasal oxygen alone (difference, −2.4% [95% CI, −6.7% to 1.7%]; P = .25).

Conclusions and Relevance  In mechanically ventilated patients at high risk of extubation failure, the use of high-flow nasal oxygen with NIV immediately after extubation significantly decreased the risk of reintubation compared with high-flow nasal oxygen alone.

DOI: 10.1001/jama.2019.14901

Source: https://jamanetwork.com/journals/jama/article-abstract/2752582