Association of sequential high-flow nasal cannula oxygen therapy with neurological recovery and clinical outcomes in neurocritical patients after extubation: a retrospective cohort study.

BACKGROUND: To evaluate the association between sequential high-flow nasal cannula (HFNC) oxygen therapy and neurological recovery, extubation outcomes, and clinical prognosis in neurocritical patients after extubation. METHODS: This single-center retrospective cohort study included 186 critically ill patients with neurological disorders who received mechanical ventilation and were successfully extubated between August 2023 and December 2025. According to the oxygen therapy modality during the peri-extubation period, patients were assigned to the HFNC group (n = 112) or the mask group (n = 74). The primary outcome was extubation failure. Patients received HFNC or conventional mask oxygen therapy according to attending physician judgement based on respiratory status, airway secretion burden, oxygenation requirement, and perceived extubation risk. Secondary outcomes included neurological recovery, time to neurological recovery, Barthel Index, and in-hospital outcomes. Multivariable logistic regression, linear mixed-effects models, and Kaplan-Meier analyses were used to evaluate intergroup differences. RESULTS: The HFNC group showed a lower rate of extubation failure compared with the mask group (15.2% vs 32.4%, P = 0.005). In multivariable analysis, HFNC use remained independently associated with lower extubation failure. Neurological recovery was faster in the HFNC group, with a significant group-by-time interaction (both P < 0.001). Kaplan-Meier analysis showed a significantly shorter time to neurological recovery in the HFNC group (median time: 41 h vs. 60 h; hazard ratio [HR] = 1.65, P = 0.003). In addition, oxygenation was significantly improved in the HFNC group, accompanied by reduced respiratory workload, better functional outcomes, and shorter length of hospital stay (all P < 0.05). Sensitivity analyses yielded consistent results. CONCLUSION: HFNC may represent an important oxygen therapy strategy during the peri-extubation period in neurocritical care.