Beneficial Effects of Noninvasive Ventilation after Extubation in Obese or Overweight Patients: A <i>Post Hoc</i> Analysis of a Randomized Clinical Trial
Arnaud W. Thille, Rémi Coudroy, Mai-Anh Nay, Arnaud Gacouin, Maxens Decavèle, Romain Sonneville, François Beloncle, Christophe Girault, Laurence Dangers, Alexandre Lautrette, Quentin Levrat, Anahita Rouzé, Emmanuel Vivier, Jean-Baptiste Lascarrou, Jean-Damien Ricard, Armand Mekontso-Dessap, Guillaume Barberet, Christine Lebert, Stephan Ehrmann, Alexandre Massri, Jeremy Bourenne, Gael Pradel, Pierre Bailly, Nicolas Terzi, Jean Dellamonica, Guillaume Lacave, René Robert, Jean-Pierre Frat, Stéphanie Ragot
Abstract
Abstract Rationale Although noninvasive ventilation (NIV) may prevent reintubation in patients at high risk of extubation failure in ICUs, this oxygenation strategy has not been specifically assessed in obese patients. Objectives We hypothesized that NIV may decrease the risk of reintubation in obese patients compared with high-flow nasal oxygen. Methods Post hoc analysis of a multicenter randomized controlled trial (not prespecified) comparing NIV alternating with high-flow nasal oxygen versus high-flow nasal oxygen alone after extubation, with the aim of assessing NIV effects according to patient body mass index (BMI). Measurements and Main Results Among 623 patients at high risk of extubation failure, 206 (33%) were obese (BMI ⩾ 30 kg/m2), 204 (33%) were overweight (25 kg/m2 ⩽ BMI &lt; 30 kg/m2), and 213 (34%) were normal or underweight (BMI &lt; 25 kg/m2). Significant heterogeneity of NIV effects on the rate of reintubation was found according to BMI (P interaction = 0.007). Reintubation rates at Day 7 were significantly lower with NIV alternating with high-flow nasal oxygen than with high-flow nasal oxygen alone in obese or overweight patients: 7% (15/204) versus 20% (41/206) (difference, −13% [95% confidence interval, −19 to −6]; P = 0.0002), whereas it did not significantly differ in normal or underweight patients. In-ICU mortality was significantly lower with NIV than with high-flow nasal oxygen alone in obese or overweight patients (2% vs. 9%; difference, −6% [95% confidence interval, −11 to −2]; P = 0.006). Conclusions Prophylactic NIV alternating with high-flow nasal oxygen immediately after extubation significantly decreased the risk of reintubation and death compared with high-flow nasal oxygen alone in obese or overweight patients at high risk of extubation failure. By contrast, NIV was not effective in normal or underweight patients. Clinical trial registered with www.clinicaltrials.gov (NCT03121482).