What is the efficacy of humidified noninvasive ventilation (NIV) compared to high-flow therapy (HFT) in preventing reintubation in patients with obesity?

From the Guidelines

Humidified noninvasive ventilation (NIV) is the preferred method for preventing reintubation in patients with obesity after planned extubation, as it has been shown to be more effective than high-flow nasal therapy (HFNT) in reducing reintubation rates and post-extubation respiratory failures. This recommendation is based on the most recent and highest quality evidence available, which suggests that NIV can overcome upper airway obstruction and atelectasis common in obese patients, while providing positive pressure support that counteracts increased work of breathing 1.

The benefits of NIV in this population are thought to be due to its ability to provide positive pressure support, which can help to improve lung volumes and reduce the work of breathing, thereby reducing the risk of reintubation and post-extubation respiratory failure. In contrast, HFNT, while improving patient comfort and limiting the risk of NIV-related adverse events, may not provide the same level of positive pressure support as NIV, and therefore may not be as effective in preventing reintubation in obese patients 1.

Key considerations for the use of NIV in this population include:

• Initial inspiratory positive airway pressure of 12 cmH₂O and expiratory pressure of 5 cmH₂O, adjusted as needed for patient comfort
• Close monitoring of patients for signs of respiratory failure and need for reintubation
• Consideration of alternative respiratory support strategies, such as HFNT, in patients who are unable to tolerate NIV or who have contraindications to its use. The use of NIV in this population has been endorsed by recent clinical practice guidelines, which suggest that NIV can be used to prevent post-extubation respiratory failure and need for reintubation in patients at high risk of extubation failure, including those with obesity 1.

From the Research

Study Overview

• The study 2 compared humidified noninvasive ventilation (NIV) with high-flow therapy to prevent reintubation in patients with obesity.
• The trial included 144 patients with a body mass index (BMI) >30 and found that reintubation was required in 17 (23.6%) patients receiving NIV and in 24 (33.3%) patients receiving high-flow therapy.

Key Findings

• The study found no significant difference in reintubation rates between NIV and high-flow therapy 2.
• However, a post hoc Bayesian analysis suggested a 99% probability of a reduction in reintubation with NIV 2.
• Another study 3 found that prophylactic NIV alternating with high-flow nasal oxygen significantly decreased the risk of reintubation and death in obese or overweight patients at high risk of extubation failure.

Comparison with Other Studies

• A narrative review 4 suggested that noninvasive strategies, including NIV, should be used to optimize airway management in ICU patients with obesity.
• A randomized controlled trial protocol 5 aimed to compare NIV with oxygen therapy after extubation in patients with obesity in ICUs.
• A study 6 found that noninvasive positive pressure ventilation (NPPV) improved arterial oxygenation and end-expiratory lung volume (EELV) compared with conventional preoxygenation in morbidly obese patients.

Patient Outcomes

• The study 2 found that all-cause ICU mortality was not significantly different between the NIV and high-flow therapy groups.
• However, the study 3 found that in-ICU mortality was significantly lower with NIV than with high-flow nasal oxygen alone in obese or overweight patients.
• The study 6 found that NPPV combined with early recruitment maneuver improved respiratory function after endotracheal intubation in morbidly obese patients.