[Use of high-flow nasal oxygen therapy after extubation]

The decision of extubation is difficult in ICUs because in case of reintubation mortality is particularly high. High-flow nasal cannula oxygen therapy (HFNC) and noninvasive ventilation (NIV) are two respiratory supports that help to improve oxygenation, to decrease work of breathing and to decrease the risk of reintubation in selected patients. In the ICU, HFNC seems effective in patient with mild hypoxemia at time of extubation (risk of reintubation<10%) while prophylactic NIV is particularly effective in patients at high-risk of extubation failure (risk of reintubation>20%). Patients older than 65 years, those with underlying chronic cardiac or respiratory disease, or with hypercapnia are patients at high-risk easily identified at time of extubation. The best oxygenation strategy for management of post-extubation respiratory failure is unknown. HFNC has never been assessed in this setting, and NIV may have deleterious effects in patients with post-extubation respiratory failure. In postoperative patients, standard oxygen is sufficient even after major planned surgery (risk of intubation<5%), but should probably be switched to HFNC in patients with hypoxemia (risk of intubation 10-15%) and further to NIV in patients with respiratory failure with hypoxemia and clinical signs of respiratory distress (risk of intubation 50%).