Weaning patients off mechanical ventilation with NIV

Learn how to prevent and treat your patient's post-extubation respiratory failure with noninvasive ventilation (NIV).
Last update26th Nov 2020

When removing patients from mechanical ventilation, physicians are faced with a sobering fact—up to 15–20% of patients will require reintubation within 48 hours. And, patients who are reintubated after an unsuccessful extubation have a worse prognosis, even when controlling for the severity of their illness.

Noninvasive ventilation (NIV) can be used to try to treat post-extubation respiratory failure—or be used to attempt to prevent post-extubation respiratory failure before it occurs. Here, we’ll examine whether NIV is effective in each of these scenarios.

Can NIV be used to prevent post-extubation respiratory failure?

There have been a few studies that have looked at routine extubation to NIV compared with extubation to standard treatment, such as a nonrebreather mask.

There was no conclusive difference between these two groups in the rate of reintubation, suggesting that NIV did not prevent the onset of post-extubation respiratory failure, and provided no benefit when routinely used after extubation.

However, several studies have examined the effects of NIV in older patients with cardiac or respiratory comorbidities who were at high-risk of failure of extubation. Most showed improvements in the rates of respiratory failure, reintubation, and mortality when NIV was applied.

Figure 1. Noninvasive ventilation (NIV) can help lower reintubation, mortality, and respiratory failure in older patients with cardiac or respiratory comorbidities.

One subset of patients with respiratory disease at high-risk for reintubation has been looked at with greater frequency than other groups. Patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) can benefit from the use of NIV when weaning from mechanical ventilation. Even when these patients do not pass a spontaneous breathing trial (SBT), extubation to NIV can result in improved mortality, decreased weaning failure, and decreased incidence of ventilator-associated pneumonia (VAP).

Figure 2. Noninvasive ventilation (NIV) can help lower mortality, reintubation, and ventilator-associated pneumonia (VAP) in patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD).

Since treating all patients after extubation with NIV may only help some, you might be wondering if you can wait until patients develop overt respiratory failure after extubation before applying NIV?

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Can NIV help treat post-extubation respiratory failure?

Despite positive results from some early case-control studies, further investigation found no improvement in patients when NIV was used after the development of respiratory failure. In fact, in the largest trial, patients actually did worse when NIV was applied—possibly because the use of NIV delayed endotracheal intubation.

Now you know that NIV does not have a role in the treatment of patients undergoing routine extubation, and isn’t effective in treating patients with signs of respiratory failure. But to improve liberation from mechanical ventilation, use NIV in patients with cardiorespiratory comorbidities at a high-risk for reintubation or patients who have AECOPD.

That’s it for now. If you want to improve your understanding of key concepts in medicine and improve your clinical skills, make sure to register for a free trial account, which will give you access to free videos and downloads. We’ll help you make the right decisions for yourself and your patients.

Recommended reading

  • Baillard, C, Fosse, JP, Sebbane, M, et al. 2006. Noninvasive ventilation improves preoxygenation before intubation of hypoxic patients. Am J Respir Crit Care Med. 174: 171–177. PMID: 16627862
  • Esteban, A, Frutos-Vivar, F, Ferguson, ND, et al. 2004. Noninvasive positive-pressure ventilation for respiratory failure after extubation. N Engl J Med. 350: 2452–2460. PMID: 15190137
  • Ferrer, M, Sellarés, J, Valencia, M, et al. 2009. Non-invasive ventilation after extubation in hypercapnic patients with chronic respiratory disorders: randomised controlled trial. Lancet. 374: 1082–1088. PMID: 19682735
  • Wilson, ME, Majzoub, AM, Dobler, CC, et al. 2018. Noninvasive ventilation in patients with Do-Not-Intubate and Comfort-Measures-Only orders: a systematic review and meta-analysis. Crit Care Med. 46: 1209–1216. PMID: 29498939

About the author

Michael Allison, MD
Chief of Critical Care Medicine at the University of Maryland St. Joseph Medical Center, USA.
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