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Updated: Dec 11, 2025
A Structured Approach to Extubation in Mechanically Ventilated Rats
Published on: July 18, 2025
Progression of Respiratory Support Following Pediatric Extubation
Johnny M Krasinkiewicz1, Matthew L Friedman2, James E Slaven3
1Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, IN.
Insights
High-flow nasal cannula (HFNC) and noninvasive positive pressure ventilation (NIPPV) are common after pediatric extubation, but HFNC use decreases within 72 hours. Longer ventilation increases HFNC/NIPPV use, while cerebral palsy may prompt escalation.
Area of Science:
- Pediatric critical care medicine
- Respiratory therapy
- Mechanical ventilation
Background:
- High-flow nasal cannula (HFNC) and noninvasive positive pressure ventilation (NIPPV) are widely used in pediatric intensive care units (PICUs).
- Current practice patterns for these respiratory support modalities post-extubation are not well-documented.
- Understanding these patterns is crucial for optimizing patient care and outcomes.
Purpose of the Study:
- To describe the utilization of HFNC and NIPPV in pediatric patients following extubation.
- To analyze how the use of these non-invasive ventilation methods progresses within 72 hours post-extubation.
- To identify patient factors associated with the initial use and escalation of HFNC and NIPPV.
- To document interventions for postextubation stridor.
Main Methods:
- Retrospective cohort study of 427 pediatric patients in a quaternary medical-surgical PICU.
- Data collected on respiratory support modality use for the first 72 hours after extubation.
- Multivariate analysis to identify factors influencing HFNC and NIPPV use and escalation.
Main Results:
- Initial extubation to HFNC (30.9%) or NIPPV (5.4%) was less common than nasal cannula (51.8%) or room air (11.9%).
- Within 72 hours, room air use increased significantly, while HFNC and NIPPV use decreased.
- HFNC was the primary modality for postextubation stridor.
- Prolonged invasive mechanical ventilation increased initial HFNC/NIPPV use; cerebral palsy increased escalation from HFNC to NIPPV.
Conclusions:
- HFNC is frequently used initially post-extubation and for stridor, but its use declines within 72 hours.
- Further multicenter research is needed to identify pediatric patients at high risk for extubation failure who may benefit from prophylactic HFNC or NIPPV.
Objectives:
High-flow nasal cannula and noninvasive positive pressure ventilation have become ubiquitous in contemporary PICUs. Practice patterns associated with the use of these modalities have not been well described. In this study, we aimed to describe the use of high-flow nasal cannula and noninvasive positive pressure ventilation in children after extubation and analyze the progression of usage in association with patient factors. Our secondary aim was to describe interventions used for postextubation stridor.
Design:
Single-center retrospective cohort study.
Setting:
A 36-bed quaternary medical-surgical PICU.
Patients:
Mechanically ventilated pediatric patients admitted between April 2017 and March 2018. Exclusions were patients in the cardiac ICU, patients requiring a tracheostomy or chronic ventilatory support, and patients with limited resuscitation status.
Interventions:
None.
Measurements And Main Results:
Data regarding respiratory modality use was collected for the first 72 hours after extubation. There were 427 patients included in the analysis; 51 patients (11.9%) were extubated to room air, 221 (51.8%) to nasal cannula, 132 (30.9%) to high-flow nasal cannula, and 23 (5.4%) to noninvasive positive pressure ventilation. By 72 hours, 314 patients (73.5%) were on room air, 52 (12.2%) on nasal cannula, 29 (6.8%) on high-flow nasal cannula, eight (1.9%) on noninvasive positive pressure ventilation, and 24 (5.6%) were reintubated. High-flow nasal cannula was the most used respiratory modality for postextubation stridor. Multivariate analysis demonstrated that longer duration of invasive mechanical ventilation increased the odds of initial high-flow nasal cannula and noninvasive positive pressure ventilation use, and a diagnosis of cerebral palsy increased the odds of escalating from high-flow nasal cannula to noninvasive positive pressure ventilation in the first 24 hours post extubation.
Conclusions:
High-flow nasal cannula is commonly used immediately after pediatric extubation and the development of postextubation stridor; however, its usage sharply declines over the following 72 hours. Larger multicenter trials are needed to identify high-risk patients for extubation failure that might benefit the most from prophylactic use of high-flow nasal cannula and noninvasive positive pressure ventilation after extubation.
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