Noninvasive Respiratory Support for Postextubation Respiratory Failure

The rate of re-intubation after endotracheal extubation for all indications is estimated at ∼20%. This high rate is related, in part, to the development of postoperative complications that leads to acute respiratory failure that requires re-intubation. In general, 5-10% of all surgical patients develop postoperative respiratory failure, and, in patients who require abdominal surgery, up to 40% develop respiratory failure. The forms of respiratory support that have been shown to be most effective in managing postextubation respiratory failure and preventing re-intubation are noninvasive ventilation, CPAP, and high-flow nasal cannula. From an analysis of the data, it is clear that patients at high risk of re-intubation require CPAP, noninvasive ventilation, or high-flow nasal cannula after extubation to allow for a smooth transition to spontaneous breathing and to minimize the need for re-intubation. CPAP is most indicated in patients with atelectasis in which high levels of PEEP are needed, noninvasive ventilation is indicated in the patient unable to maintain an adequate minute ventilation without excessive work of breathing, and high-flow nasal cannula is indicated in the patient with severe hypoxemia that was not a result of marked atelectasis or severe ARDS. It is also clear that there are insufficient data to support the use of any of these therapies in patients at low risk for re-intubation or the development of postoperative pulmonary complications.