Domenico Luca Grieco, Samir Jaber, Spyros Zakynthinos, Alexandre Demoule, Jean-Damien Ricard, Paolo Navalesi, Rosanna Vaschetto, Sami Hraiech, Kada Klouche, Jean Pierre Frat, Virginie Lemiale, Vito Fanelli, Gérald Chanques, Federico Longhini, Jordi Mancebo, Maria Rosaria Gualano, Bruno L. Ferreyro, Laurent Brochard, Massimo Antonelli, Salvatore Maurizio Maggiore, the RINO trial study group, Daniele Natalini, Eleni Ischaki, Danielle Reuter, Indalecio Morán, Béatrice La Combe, Andrea De Gaetano, V. Marco Ranieri, Yassir Aarab, Élie Azoulay, Fouad Belafia, Guillaume Berquier, Matthieu Conseil, Andrea Costamagna, Laurence Dangers, Audrey De Jong, Julie Delemazure, Françesco Della Corte, Stèphane Gaudry, Francesca Grossi, Giovanni Carmine Iovino, Sylvain Jean‐Baptiste, Mohammed Laissi, Romaric Larcher, Matthieu Le Meur, Clément Leclaire, Paula Andrea Lopez, Sotirios Malachias, Marilena Matteo, Julienne Mayaux, Jonathan Messika, Clément Monet, Élise Morawiec, Laurent Papazian, Francisco Parrilla, Laura Platon, Damien Roux, Maria Teresa Santantonio, J.C. Suarez Montero, Eloisa Sofia Tanzarella, Flavia Toni, Luca S. Menga
BACKGROUND: Robust evidence supports the use of preemptive non-invasive ventilation (NIV) after extubation in selected high-risk patient cohorts. In contrast, current guidelines discourage the use of NIV as a rescue therapy for respiratory failure that develops later after extubation, based on earlier studies indicating a potential increase in hospital mortality due to delayed reintubation. Nonetheless, NIV continues to be employed in this setting. We conducted a post-hoc analysis of a randomized trial to assess the clinical outcomes of rescue NIV for post-extubation respiratory failure. METHODS: In this post-hoc analysis of a randomized trial comparing high-flow with Venturi mask oxygen in hypoxemic patients after extubation, we included those who developed post-extubation respiratory failure according to prespecified criteria; patients who received rescue NIV per physician's decision were compared to those who received direct re-intubation. Criteria for re-intubation during NIV were prespecified. Odds ratio after inverse probability of treatment weighting and posterior probabilities by Bayesian regression are reported. RESULTS: Among 494 extubated patients, 147 developed respiratory failure while receiving oxygen therapy, occurring at a median of 37 h [IQR 13-85] after extubation: 83 (57%) were treated with rescue NIV and 64 (43%) received immediate re-intubation. The rate of NIV failure was 58%, without differences between patients with hypoxemic respiratory failure and those with hypercapnia and/or respiratory distress (60% vs. 56%, p = 0.82). In the weighted cohort, the use of rescue NIV, compared to direct re-intubation, was associated with lower intensive care unit mortality (adjusted odds ratio = 0.31 [95%CI: 0.12-0.82], p = 0.019) and similar hospital mortality (adjusted odds ratio = 1.01 [95%CI: 0.43-2.33], p = 0.99). The posterior probability that NIV reduced intensive care unit mortality was > 90% across all priors. The posterior probability that NIV did not increase hospital mortality was 44% under a noninformative prior, 47% under a skeptical prior, and 39% under a pessimistic prior. CONCLUSION: Rescue NIV for post-extubation respiratory failure is associated with high failure rates; however, when applied with well-defined criteria for reintubation, it does not appear to be clearly associated with increases in hospital mortality. A randomized trial to re-evaluate the efficacy of rescue NIV for post-extubation respiratory failure is warranted. CLINICAL TRIAL REGISTRATION: Registered at clinicaltrials.gov (NCT02107183) on April 8th, 2014.