An article published Online First and in a future edition of The Lancet, reports that patients who are given early non-invasive ventilation after extubation have a lower risk of death and respiratory failure than those who are given normal oxygen therapy. Patients with chronic respiratory disorders are at increased risk of respiratory failure and subsequent death when they have the internal tubing used to assist their breathing removed (extubation). The article is the work of Dr Miquel Ferrer, Hospital Clínic of Barcelona, Universitat de Barcelona, Spain, and collaborators.

The authors in this randomised controlled study examined particularly patients with chronic respiratory disorders who were hypercapnic. They all had high levels of carbon dioxide in their blood before extubation. As suggested from previous studies, this population was considered as one that could benefit most from the intervention. The researchers enrolled 106 mechanically ventilated patients with chronic respiratory disorders and hypercapnia. Following extubation, 54 patients received non-invasive ventilation for 24 hours and 52 received conventional oxygen treatment. The primary endpoint was prevention of respiratory failure within 72 hours after extubation.

Findings showed that respiratory failure after extubation was less frequent in patients assigned non-invasive ventilation (15 percent of patients) than in those allocated conventional oxygen therapy (48 percent of patients). In patients with respiratory failure, non-invasive ventilation as rescue therapy avoided reintubation in 17 of 27 patients. Non-invasive ventilation was related with an 83 percent drop in risk of respiratory failure after extubation. This reduction was independent from other potential factors. After 90 days, mortality was inferior in patients assigned non-invasive ventilation (11 percent) than in those allocated conventional oxygen (31 percent).

The authors write in conclusion: "Early non-invasive ventilation after extubation diminished risk of respiratory failure and lowered 90-day mortality in patients with hypercapnia during a spontaneous breathing trial. Routine implementation of this strategy for management of mechanically ventilated patients with chronic respiratory disorders is advisable."

In an associated note, Dr Peter Calverley, of the University Hospital Aintree, Liverpool, UK, writes: "Hopefully, data such as these will change our perceptions of how and when aggressive treatment should be offered to the many patients with chronic obstructive pulmonary disease who still need this form of help."

"Non-invasive ventilation after extubation in hypercapnic patients with chronic respiratory disorders: randomised controlled trial"
Miquel Ferrer, Jacobo Sellarés, Mauricio Valencia, Andres Carrillo, Gumersindo Gonzalez, Joan Ramon Badia, Josep Maria Nicolas, Antoni Torres
DOI: 10.1016/S0140-6736(09)61038-2
The Lancet

Stephanie Brunner (B.A.)