Postextubation respiratory failure (PRF) frequently complicates weaning from mechanical ventilation and may increase morbidity/mortality. Noninvasive ventilation (NIV) alternating with high-flow nasal oxygen (HFNO) may prevent PRF. Ventilated patients without chronic obstructive pulmonary disease (COPD) and at high-risk of PRF defined as a lung ultrasound score (LUS) ≥ 14 assessed during the spontaneous breathing trial, were included in a French-Chinese randomised controlled trial. PRF was defined by 2 among the following signs: SpO2 < 90%; Respiratory rate > 30 /min; hypercapnia; haemodynamic and/or neurological disturbances of respiratory origin. In the intervention group, prophylactic NIV alternating with HFNO was administered for 48 h following extubation. In the control group, conventional oxygen was used. Clinicians were informed on the LUS in the intervention group, those in the control group remained blind. The primary outcome was the incidence of PRF 48 h after extubation. Secondary outcomes were incidence of PRF and reintubation at day 7, number of ventilator-free days at day 28, length of ICU stay and mortality at day 28 and 90. Two hundred and forty patients were randomised and 227 analysed (intervention group = 128 and control group = 99). PRF at H48 was reduced in the intervention group compared to the control group: relative risk 0.52 (0.31 to 0.88), p = 0.01. The benefit persisted at day 7: relative risk 0.62 (0.44 to 0.96), p = 0.02. Weaning failure imposing reconnection to mechanical ventilation was not reduced. In patients who developed PRF and were treated by rescue NIV, reintubation was avoided in 44% of control patients and in 12% of intervention patients (p = 0.008). Other secondary outcomes were not different between groups. From a resource utilisation standpoint, prophylactic NIV alternating with HFNO was more demanding and costly than conventional oxygen with rescue NIV to achieve same clinical outcome. Compared to conventional oxygenation, prophylactic NIV alternating with HFNO significantly reduced postextubation respiratory failure but failed to reduce reintubation rate and mortality in patients without COPD at high risk of extubation failure. Prophylactic NIV alternating with HFNO was as efficient as recue NIV to treat postextubation respiratory failure.

中文翻译：

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通过肺部超声评估拔管失败高危非 COPD 患者的脱机： WIN IN WEAN 多中心随机对照试验


拔管后呼吸衰竭 （PRF） 经常使机械通气脱机复杂化，并可能增加发病率/死亡率。无创通气 （NIV） 与高流量鼻氧 （HFNO） 交替使用可预防 PRF。无慢性阻塞性肺病 （COPD） 且处于 PRF 高风险中的通气患者被纳入一项法中随机对照试验，定义为肺部超声评分 （LUS） ≥ 14。PRF 由以下体征中的 2 定义： SpO2 < 90%;呼吸频率 > 30 /min;高碳酸血症;呼吸源性的血液动力学和/或神经系统障碍。干预组拔管后预防性 NIV 与 HFNO 交替给药 48 h。在对照组中，使用常规氧气。干预组的临床医生被告知 LUS，对照组的临床医生保持盲人。主要结局是拔管后 48 h PRF 的发生率。次要结局是第 7 天 PRF 和再插管的发生率、第 28 天无呼吸机的天数、ICU 住院时间以及第 28 天和第 90 天的死亡率。240 例患者被随机分组并分析 227 例 （干预组 = 128 例，对照组 = 99）。与对照组相比，干预组 H48 的 PRF 降低：相对风险 0.52 （0.31 至 0.88），p = 0.01。获益在第 7 天持续存在：相对风险 0.62 （0.44 至 0.96），p = 0.02。需要重新连接到机械通气的脱机失败没有减少。在发生 PRF 并接受抢救 NIV 治疗的患者中，44% 的对照患者和 12% 的干预患者避免了再插管 （p = 0.008）。其他次要结局在组间没有差异。 从资源利用的角度来看，预防性 NIV 与 HFNO 交替使用比传统氧气联合抢救 NIV 更苛刻、更昂贵，以达到相同的临床结局。与传统氧合相比，预防性 NIV 与 HFNO 交替治疗可显著降低拔管后呼吸衰竭，但未能降低拔管失败风险高的无 COPD 患者的再插管率和死亡率。预防性 NIV 与 HFNO 交替治疗拔管后呼吸衰竭与补救 NIV 一样有效。