do not use bipap for rescue failed extubation

This patient has failed a trial of extubation, with acutely worsening respiratory failure after a prolonged mechanical ventilation course. She was not hypercapnic on her spontaneous breathing trial. The reasons for her extubation failure are not clear at this time, but an easily reversible cause is not readily apparent. She should be reintubated with reinitiation of mechanical ventilation.

BPAP or noninvasive ventilation should not be used in attempts at rescuing patients who fail extubation (called therapeutic noninvasive ventilation) and are not chronically hypercapnic or hypercapnic on a spontaneous breathing trial immediately prior to extubation. A multicenter randomized trial demonstrated that attempts at rescuing these patients with BPAP led to delayed intubation and higher mortality than did immediate reintubation in patients who have recurrent respiratory failure shortly after extubation. Subsequent randomized trials suggested that extubating patients who are high risk directly to noninvasive ventilation (called prophylactic noninvasive ventilation) or high-flow nasal cannula oxygen may decrease postextubation recurrent respiratory failure and need for reintubation. This patient was extubated to high-flow nasal cannula oxygen but experienced postextubation respiratory failure anyway. Additional randomized trials suggest that BPAP might be safely and successfully used to rescue patients with chronic hypercapnia who develop respiratory failure shortly after extubation from mechanical ventilation.12345

Footnotes

  1. SEEK Questionnaires ↩

  2. :1 Esteban A, Frutos-Vivar F, Ferguson ND, et al. Noninvasive positive-pressure ventilation for respiratory failure after extubation. N Engl J Med. 2004;350(24):2452-2460. doi:10.1056/NEJMoa032736 ↩

  3. Ferrer M, Valencia M, Nicolas JM, et al. Early noninvasive ventilation averts extubation failure in patients at risk: a randomized trial. Am J Respir Crit Care Med. 2006;173(2):164-170. PubMed ↩

  4. Keenan SP, Powers C, McCormack DG, et al. Noninvasive positive-pressure ventilation for postextubation respiratory distress: a randomized controlled trial. JAMA. 2002;287(24):3238-3244. PubMed ↩

  5. Nava S, Gregoretti C, Fanfulla F, et al. Noninvasive ventilation to prevent respiratory failure after extubation in high-risk patients. Crit Care Med. 2005;33(11):2465-2470. PubMed ↩