What is the role of bridging therapy after extubation (removal of endotracheal tube) in critically ill patients?

From the Guidelines

Bridging therapy with non-invasive ventilation (NIV) immediately after extubation is recommended for critically ill patients at high risk of extubation failure, as it reduces the need for reintubation and ICU mortality. The use of NIV in this context is supported by a study published in the journal Chest in 2017 1, which found that NIV was favored over standard care in high-risk patients following extubation, with a reduced need for reintubation and ICU mortality.

Key Considerations for Bridging Therapy

• Patient selection: High-risk patients, including those with hypercapnia, COPD, cardiac failure, or older age, should be considered for NIV immediately after extubation.
• NIV settings: Initial settings of 8-12 cmH2O inspiratory pressure and 4-6 cmH2O expiratory pressure can be used, titrated based on patient comfort and work of breathing.
• Alternative options: High-flow nasal cannula (HFNC) can be used as an alternative to NIV, particularly in patients who are not hypercapnic or have COPD, with initial flow rates of 30-60 L/min and FiO2 titrated to maintain SpO2 >92%.
• Duration of therapy: Bridging therapy typically ranges from 24-48 hours, with gradual weaning as the patient stabilizes.
• Monitoring: Patients should be closely monitored for signs of respiratory distress, including increased respiratory rate, accessory muscle use, or decreasing oxygen saturation, which may indicate the need for reintubation.

Benefits of Bridging Therapy

• Reduces the need for reintubation: NIV has been shown to reduce the need for reintubation in high-risk patients, as demonstrated in the study by Ferrer et al, which found that patients receiving NIV had reduced reintubation rates compared to those receiving standard care 1.
• Improves ICU mortality: NIV has also been shown to improve ICU mortality, with a study by Nava et al finding that the NIV group had a reduced ICU mortality compared to the standard care group 1.
• Enhances patient comfort: Bridging therapy can improve patient comfort by reducing the work of breathing and providing positive pressure to prevent alveolar collapse.

From the Research

Bridging Therapy after Extubation in Critically Ill Patients

Bridging therapy after extubation in critically ill patients is crucial to prevent reintubation and improve outcomes. The following are some key points to consider:

• The decision to extubate is critical, as mortality is high in case of reintubation 2.
• Around 15% of patients ready to be weaned off a ventilator experience extubation failure leading to reintubation 2.
• High-flow nasal oxygen and non-invasive ventilation are two alternatives to standard oxygen supplementation that may help prevent reintubation 2, 3.
• Non-invasive ventilation may be used to prevent reintubation in patients with high risk of reintubation, such as those >65 years and those with underlying cardiac disease, chronic respiratory disorders, and/or hypercapnia at the time of extubation 2.
• High-flow nasal cannula (HFNC) is a potential alternative treatment to non-invasive ventilation (NIV) for patients with acute hypercapnic respiratory failure, but its effectiveness is still uncertain 4.
• BiPAP therapy was more efficient than HFNC in preventing tracheal reintubation among patients with a high risk of extubation failure 5.
• The preventive use of NIV is probably the most effective respiratory support method for comprehensively preventing re-intubation and short-term death in critically ill medical patients, especially those with a high risk of extubation failure 6.

Comparison of Respiratory Support Methods

The following are some key points to consider when comparing respiratory support methods:

• NIV significantly reduced the re-intubation rate and short-term mortality compared to conventional oxygen therapy (COT) 6.
• HFOT had a beneficial effect on the re-intubation rate but no effect on short-term mortality compared to COT 6.
• No significant difference in the re-intubation rate or short-term mortality was found among NIV, HFOT, and HFOT+NIV 6.
• The treatment rankings based on the surface under the cumulative ranking curve (SUCRA) from best to worst for re-intubation rate were HFOT+NIV, NIV, HFOT, and COT 6.

Patient Selection and Monitoring

The following are some key points to consider when selecting patients for bridging therapy and monitoring their progress:

• Patients with low risk of reintubation may benefit from high-flow nasal oxygen, while those with high risk may benefit from non-invasive ventilation 2.
• Patients with acute hypercapnic respiratory failure may benefit from HFNC or NIV, but the choice of therapy should be individualized based on patient characteristics and preferences 4.
• Continuous monitoring for signs of respiratory distress and failure is essential after extubation, regardless of the respiratory support method used 5.