Using HFNC to increase the success of extubation

Learn how to increase the success of extubation using high-flow nasal cannula (HFNC). Read our Clinical Guide.
Last update26th Nov 2020

Despite the benefits of high-flow nasal cannula (HFNC) in reducing the need for intubation in patients with moderate and severe lung injury, 30% of patients may end up requiring intubation and mechanical ventilation. Since high-flow nasal cannula can improve oxygen delivery, wash out upper airway dead space, and improve the functional residual capacity, let’s evaluate HFNC for respiratory support after extubation.

Consider a patient with pneumonia. Despite antibiotics and the use of high flow oxygen for hypoxia, the patient worsens and requires mechanical ventilation. After five days of excellent intensive care unit (ICU) care, the patient is passing a spontaneous breathing trial (SBT) and ready for extubation.

Role of HFNC after extubation

Traditionally, patients would be extubated to a traditional nasal cannula. Noninvasive ventilation (NIV) would be used for patients with continued hypercapnia during the breathing trial or those considered high-risk for extubation failure.

HFNC has been found to reduce the need for reintubation after liberation from mechanical ventilation. HFNC has been evaluated in patients with both a low-risk for reintubation and a high-risk for reintubation.

HFNC use in patients at low-risk for reintubation

Patients who are low-risk for reintubation are generally young, have few comorbidities, were not intubated very long and passed their first attempted SBT. These are patients that most clinicians would predict would do very well after extubation.

Remarkably, the use of high-flow nasal cannula in this low-risk cohort reduced the risk of reintubation by 7% when compared to conventional oxygen given by nasal cannula or face mask.

Figure 1. Patients at low-risk of reintubation are young, without many comorbidities, not intubated for very long, and passed their first attempted spontaneous breathing trial (SBT). The use of high-flow nasal cannula (HFNC) in these patients reduced the risk of reintubation by 7% when compared to conventional oxygen given by nasal cannula or face mask.

Become a great clinician with our video courses and workshops

HFNC use in patients at high-risk for reintubation

But, what role can HFNC play in patients at high-risk for reintubation?

Patients without the low-risk features previously discussed—those that are older, were intubated longer, had congestive heart failure or chronic obstructive pulmonary disease (COPD), and were hypercapnic—were studied to determine the need for reintubation.

In the high-risk cohort, there was no statistical difference in failure when extubating to the HFNC compared to NIV mask, suggesting that HFNC is equally as effective in patients at highest risk for reintubation.

Figure 2. Patients at high-risk of reintubation are older, have congestive heart failure (CHF) or chronic obstructive pulmonary disease (COPD), intubated longer, and hypercapnic. For this patient group, there is no statistical difference in failure rates between extubating to the high-flow nasal cannula (HFNC), and the noninvasive ventilation (NIV) mask.

So, high-flow nasal cannula, or HFNC, can reduce the risk of reintubation in low or high-risk patients by a value greater than or equal to that of conventional approaches.

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

  • Dysart, K, Miller, TL, Wolfson, MR, et al. 2009. Research in high flow therapy: mechanisms of action. Respir Med103: 1400–1405. PMID: 19467849
  • Frat, JP, Thille, AW, Girault, C, et al. 2015. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med372: 2185–2196. PMID: 25981908
  • Hernández, G, Vaquero C, Colinas, L, et al. 2016. Effect of postextubation high-flow nasal cannula vs noninvasive ventilation on reintubation and postextubation respiratory failure in high-risk patients: a randomized clinical trial. JAMA316: 1565–1574. PMID: 27706464
  • Hernández, G, Vaquero C, González, P, et al. 2016. Effect of postextubation high-flow nasal cannula vs conventional oxygen therapy on reintubation in low-risk patients: a randomized clinical trial. JAMA315: 1354–1361. PMID: 26975498
  • Maggiore, SM, Idone, FA, Vaschetto, R, et al. 2014. Nasal high-flow versus venturi mask oxygen therapy after extubation. Effects of oxygenation, comfort and clinical outcome. Am J Respir Crit Care Med190: 282–288. PMID: 25003980
  • Mauri, T, Turrini, C, Eronia, N, et al. 2017. Physiologic effects of high-flow nasal cannula in acute hypoxemic respiratory failure. Am J Respir Crit Care Med195: 1207–1215. PMID: 27997805
  • Roca, O, Caralt, B, Messika, J, et al. 2019. An index combining respiratory rate and oxygenation to predict outcome of nasal high-flow therapy. Am J Respir Crit Care Med199: 1368–1376. PMID: 30576221
  • Roca, O, Messika, J, Caralt, B, et al. 2016. Predicting success of high-flow nasal cannula in pneumonia patients with hypoxemic respiratory failure: the utility of the ROX index. J Crit Care35: 200–205. PMID: 27481760
  • Sztrymf, B, Messika, J, Bertrand, F, et al. 2011. Beneficial effects of humidified high flow nasal oxygen in critical care patients: a prospective pilot study. Intensive Care Med37: 1780–1786. PMID: 21946925

About the author

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