NIV can play a role after invasive mechanical ventilation in post-extubation periods. The main reasons to use NIV after extubations are to reduce the length of invasive ventilation and to prevent extubation failure. However, NIV can also be used in cases confirmed as extubation failure but many authors suggest caution in this regard.
Since morbidity and mortality increase along with the duration of invasive ventilation, most would agree that shortening the time of invasive ventilation is best practice when this is possible. NIV can be used to reduce the length of invasive ventilation and help wean in some patients.
In the article “The role of Noninvasive ventilation in the Ventilation Discontinuance process”, Hess states that patients who need to be intubated during a COPD exacerbation and who don’t complete the spontaneous breathing trial, or patients suffering from neuromuscular disease, are candidates for NIV treatment after extubation.¹
This was demonstrated by Nava et al. in a study where patients with AHRF who had been intubated were randomized to two therapy groups following a failed t-piece trial. COPD patients randomized to weaning using NIV as an alternative to conventional weaning of pressure support administered invasively had fewer days ventilated and shorter LOS in ICU. In this study, fewer patients weaned using NIV died and developed VAP, whereas 7 out of 25 patients in the invasively weaned group developed this severe complication.²
NIV can be used as an instrument to prevent re-intubation in patients weaned off invasive mechanical ventilation. The group of patients that have experienced the best results are those who are identified at risk of extubation failure although they successfully completed the spontaneous breathing test. NIV directly after extubation may work to prevent extubation failure and thus eventually re-intubation.
Agarwall et al. recommends NIV for those patients “[...]as a prophylaxis to prevent re-intubation in patients “at risk” for developing post-extubation respiratory failure.”³
In situations of extubation failure within 48 hours post-extubation, NIV should only be used judiciously. According to current evidence, NIV does not decrease the re-intubation rate or intensive care unit mortality compared to the standard medical therapy.³
Similarly, Hess recommends that “NIV [post extubation] is indicated only in patients with hypercapnic respiratory failure. Re-intubation should not be delayed if NIV is not immediately successful in reversing the post-extubation respiratory failure.”¹
As shown above, NIV improves weaning results by reducing the risk of post-extubation acute respiratory failure. However, evidence does not support routine use of NIV post-extubation.¹