Association of Non-Invasive Respiratory Support with Extubation Outcomes in Brain-Injured Patients Receiving Mechanical Ventilation: A Secondary Analysis of ENIO Prospective Observational Study

Taran, Shaurya; Diaz-Cruz, Camilo; Perrot, Bastien; Alvarez, Pablo; Godoy, Daniel Agustin; Gurjar, Mohan; Haenggi, Matthias; Mijangos, Julio Cesar; Pelosi, Paolo; Robba, Chiara; Schultz, Marcus J; Ueno, Yoshitoyo; Asehnoune, Karim; Cho, Sung Min; Yarnell, Christopher J; Cinotti, Raphael; Stevens, Robert D (2023). Association of Non-Invasive Respiratory Support with Extubation Outcomes in Brain-Injured Patients Receiving Mechanical Ventilation: A Secondary Analysis of ENIO Prospective Observational Study. American journal of respiratory and critical care medicine, 208(3), pp. 270-279. American Thoracic Society 10.1164/rccm.202212-2249OC

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RATIONALE

Non-invasive respiratory support using high flow nasal cannula (HFNC) or non-invasive positive pressure ventilation (NIPPV) can decrease the risk of reintubation in patients being liberated from mechanical ventilation, but effects in patients with acute brain injury are unknown.

OBJECTIVES

To evaluate the association between post-extubation non-invasive respiratory support and reintubation in patients with acute brain injury being liberated from mechanical ventilation.

METHODS

This was a secondary analysis of a prospective, observational study of mechanically ventilated patients with acute brain injury (NCT03400904). The primary endpoint was reintubation during ICU admission. We used mixed effects logistic regression models with patient-level covariates and random intercepts for hospital and country to evaluate the association between prophylactic (i.e, planned) HFNC or NIPPV and reintubation.

MEASUREMENTS AND MAIN RESULTS

1,115 patients were included from 62 hospitals and 19 countries, of whom 267 received HFNC or NIPPV following extubation (23.9%). Compared to conventional oxygen therapy, neither prophylactic HFNC nor NIPPV was associated with decreased risk of reintubation (respectively, odds ratio (OR), 0.97; 95% confidence interval (CI), 0.54-1.73; OR, 0.63; 95%CI, 0.30-1.32). Findings remained consistent in sensitivity analyses accounting for alternate adjustment procedures, missing data, shorter timeframes of extubation failure, and competing risks precluding reintubation. In a Bayesian analysis using skeptical and data-driven priors, the probability of reduced reintubation ranged from 17-34% for HFNC and 46-74% for NIPPV.

CONCLUSIONS

In a large cohort of brain-injured patients undergoing liberation from mechanical ventilation, prophylactic use of HFNC and NIPPV were not associated with reintubation. Prospective trials are needed to explore treatment effects in this population.

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