Applying NIV after extubation

In this video, we'll look at how NIV may be used to treat post-extubation respiratory failure or prevent respiratory failure before it occurs.

Michael Allison, MD
Michael Allison, MD
21st Apr 2020 • 3m read

Up to 20% of patients who are removed from mechanical ventilation will require reintubation within 48 hours of extubation—and their prognosis is generally worse! In this video, from our Noninvasive Ventilation Masterclass, we'll look at how NIV may be used to treat post-extubation respiratory failure or prevent respiratory failure before it occurs.

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Noninvasive ventilation (NIV) is a powerful therapy that clinicians can add to their ventilation toolboxes. This course will cover the indications for NIV, initiation and optimization, how to monitor patients on NIV, and how to wean them from it. We’ll delve into the controversial uses of NIV, when NIV is a first-line therapy, and how to rationally test its effectiveness in these situations.

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Video transcript

When removing patients from mechanical ventilation, physicians are faced with a sobering fact. Up to 15 to 20% of patients will require re intubation within 48 hours. Patients who are re intubated after an unsuccessful extubation have a worse prognosis, even when controlling for the severity of their illness.

Non invasive ventilation can be used to try to treat post extubation respiratory failure, or to try to prevent post extubation respiratory failure before it occurs. And this lesson will examine whether non invasive ventilation is effective in each of these scenarios. There have been a few studies that have looked at routine extubation to non invasive ventilation compared to extubation with standard treatment, such as a non rebreather mask or a face mask, or nasal cannula.

There was no conclusive difference between these two groups and the rate of reintegration, suggesting that non invasive ventilation did not prevent the onset of post extubation respiratory failure, and provided no benefit when routinely used after extubation. Several studies have examined the effects of non invasive ventilation and older patients with cardiac or respiratory comorbidities, who are at high risk of failure of extubation.

Most showed improvements in the rates of respiratory failure, re intubation, and mortality when non invasive ventilation was applied. Once subset of patients with respiratory disease at high risk for re intubation has been looked at with greater frequency than all other groups, patients with acute exacerbations of COPD can benefit from the use of non invasive ventilation when weaning from mechanical ventilation.

Even when these patients do not pass a spontaneous breathing trial, or an SPT extubation to non invasive ventilation can result in improved mortality, decreased weaning failure, and decreased incidence of ventilator associated pneumonia. Since treating all patients after extubation may only help some, you might be wondering if you can wait until patients develop overt respiratory failure after extubation before applying an IV.

Despite positive results from some early case control studies, further investigation found no improvement in patients. When non invasive ventilation was used after the development of respiratory failure. That is as rescue therapy. In the largest trial, patients actually did worse when non invasive ventilation was applied, possibly because the use of non invasive ventilation delayed endotracheal intubation an invasive mechanical ventilation.

So while non invasive ventilation can help prevent post extubation respiratory failure in some patients, it's not effective at treating post extubation respiratory failure. So now you know that non invasive ventilation 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 cardio respiratory comorbidities at a higher risk for re intubation, or in patients who have acute exacerbations of COPD.

So hope you liked this video. Absolutely make sure to check out the course this video was taken from and to register for a free trial account which will give you access to select the chapters of the course. If you want to learn how Medmastery can help you become a great clinician, make sure to watch the about mastery video. So thanks for watching, and I hope to see you again soon.