title: Intermittent noninvasive ventilation after extubation in patients with chronic respiratory disorders: a multicenter randomized controlled trial (VHYPER).
abstract: OBJECTIVE
  Early noninvasive ventilation (NIV) after extubation decreases the risk of respiratory failure and lowers 90-day mortality in patients with hypercapnia. Patients with chronic respiratory disease are at risk of extubation failure. Therefore, it could be useful to determine the role of NIV with a discontinuous approach, not limited to patients with hypercapnia. We assessed the efficacy of early NIV in decreasing respiratory failure after extubation in patients with chronic respiratory disorders.
  
  
  METHODS
  A prospective randomized controlled multicenter study was conducted. We enrolled 144 mechanically ventilated patients with chronic respiratory disorders who tolerated a spontaneous breathing trial. Patients were randomly allocated after extubation to receive either NIV (NIV group, n = 72), performed with a discontinuous approach, for the first 48 h, or conventional oxygen treatment (usual care group, n = 72). The primary endpoint was decreased respiratory failure within 48 h after extubation. Analysis was by intention to treat. This trial was registered with ClinicalTrials.gov (NCT01047852).
  
  
  RESULTS
  Respiratory failure after extubation was less frequent in the NIV group: 6 (8.5%) versus 20 (27.8%); p = 0.0016. Six patients (8.5%) in the NIV group versus 13 (18.1%) in the usual care group were reintubated; p = 0.09. Intensive care unit (ICU) mortality and 90-day mortality did not differ significantly between the two groups (p = 0.28 and p = 0.33, respectively). Median postrandomization ICU length of stay was lower in the usual care group: 3 days (IQR 2-6) versus 4 days (IQR 2-7; p = 0.008). Patients with hypercapnia during a spontaneous breathing trial were at risk of developing postextubation respiratory failure [adjusted odds ratio (95% CI) = 4.56 (1.59-14.00); p = 0.006] and being intubated [adjusted odds ratio (95% CI) = 3.60 (1.07-13.31); p = 0.04].
  
  
  CONCLUSIONS
  Early NIV performed following a sequential protocol for the first 48 h after extubation decreased the risk of respiratory failure in patients with chronic respiratory disorders. Reintubation and mortality did not differ between NIV and conventional oxygen therapy.
authors.affiliation: Service de Réanimation Médicale, Hôpital Pellegrin-Tripode, Centre Hospitalier Universitaire (CHU) de Bordeaux, 1 Place Amélie Raba-Léon, 33076, Bordeaux, France. frederic.vargas@chu-bordeaux.fr.|Centre de Recherche Cardio-Thoracique, INSERM 1045, CIC 0005, Université de Bordeaux, Bordeaux, France. frederic.vargas@chu-bordeaux.fr.
authors.forename: Frédéric
authors.identifier: http://orcid.org/0000-0002-1197-9184
authors.initials: F
authors.lastname: Vargas
authors.affiliation: Service de Réanimation Polyvalente, CHU de Limoges, Hôpital Dupuytren, Limoges, France.
authors.forename: Marc
authors.initials: M
authors.lastname: Clavel
authors.affiliation: Service de Réanimation Polyvalente, CHU de Toulouse, Hôpital Purpan, Toulouse, France.
authors.forename: Pascale
authors.initials: P
authors.lastname: Sanchez-Verlan
authors.affiliation: Service de Réanimation Polyvalente, Centre Hospitalier d'Albi, Albi, France.
authors.forename: Sylvain
authors.initials: S
authors.lastname: Garnier
authors.affiliation: Service de Réanimation Médicale, Hôpital Pellegrin-Tripode, Centre Hospitalier Universitaire (CHU) de Bordeaux, 1 Place Amélie Raba-Léon, 33076, Bordeaux, France.
authors.forename: Alexandre
authors.initials: A
authors.lastname: Boyer
authors.affiliation: Service de Réanimation Médicale, Hôpital Pellegrin-Tripode, Centre Hospitalier Universitaire (CHU) de Bordeaux, 1 Place Amélie Raba-Léon, 33076, Bordeaux, France.
authors.forename: Hoang-Nam
authors.initials: HN
authors.lastname: Bui
authors.affiliation: Service de Réanimation Médicale, Hôpital Pellegrin-Tripode, Centre Hospitalier Universitaire (CHU) de Bordeaux, 1 Place Amélie Raba-Léon, 33076, Bordeaux, France.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Clouzeau
authors.affiliation: Service de Réanimation Médicale, Hôpital Pellegrin-Tripode, Centre Hospitalier Universitaire (CHU) de Bordeaux, 1 Place Amélie Raba-Léon, 33076, Bordeaux, France.
authors.forename: Charline
authors.initials: C
authors.lastname: Sazio
authors.affiliation: Service de Réanimation Polyvalente, Centre Hospitalier d'Agen, Agen, France.
authors.forename: Aissa
authors.initials: A
authors.lastname: Kerchache
authors.affiliation: Service de Réanimation Médicale, CHU de Bordeaux, Hôpital Saint-André, Bordeaux, France.
authors.forename: Olivier
authors.initials: O
authors.lastname: Guisset
authors.affiliation: Service d'Information Médicale, CHU de Bordeaux, Pôle de Santé Publique, USMR, Bordeaux, France.
authors.forename: Antoine
authors.initials: A
authors.lastname: Benard
authors.affiliation: Service d'Information Médicale, CHU de Bordeaux, Pôle de Santé Publique, USMR, Bordeaux, France.
authors.forename: Julien
authors.initials: J
authors.lastname: Asselineau
authors.affiliation: Service de Réanimation Polyvalente, Centre Hospitalier de Libourne, Libourne, France.
authors.forename: Bernard
authors.initials: B
authors.lastname: Gauche
authors.affiliation: Service de Réanimation Médicale, Hôpital Pellegrin-Tripode, Centre Hospitalier Universitaire (CHU) de Bordeaux, 1 Place Amélie Raba-Léon, 33076, Bordeaux, France.
authors.forename: Didier
authors.initials: D
authors.lastname: Gruson
authors.affiliation: Service de Réanimation Polyvalente, CHU de Toulouse, Hôpital Purpan, Toulouse, France.|INSERM, URM 1214, Université de Toulouse, Toulouse, France.
authors.forename: Stein
authors.initials: S
authors.lastname: Silva
authors.affiliation: Service de Réanimation Polyvalente, CHU de Limoges, Hôpital Dupuytren, Limoges, France.
authors.forename: Philippe
authors.initials: P
authors.lastname: Vignon
authors.affiliation: Service de Réanimation Médicale, Hôpital Pellegrin-Tripode, Centre Hospitalier Universitaire (CHU) de Bordeaux, 1 Place Amélie Raba-Léon, 33076, Bordeaux, France.|Centre de Recherche Cardio-Thoracique, INSERM 1045, CIC 0005, Université de Bordeaux, Bordeaux, France.
authors.forename: Gilles
authors.initials: G
authors.lastname: Hilbert
mesh_terms: D000368:Aged; D060666:Airway Extubation / Q000009:adverse effects*; D002908:Chronic Disease; D005260:Female; D006801:Humans; D006935:Hypercapnia / Q000401:mortality / Q000628:therapy; D007362:Intensive Care Units / Q000706:statistics & numerical data; D057194:Intention to Treat Analysis; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D063087:Noninvasive Ventilation / Q000379:methods* / Q000401:mortality; D010102:Oxygen Inhalation Therapy / Q000379:methods; D011446:Prospective Studies; D012120:Respiration Disorders / Q000401:mortality / Q000628:therapy; D012131:Respiratory Insufficiency / Q000401:mortality / Q000517:prevention & control* / Q000628:therapy; D012307:Risk Factors; D015300:Ventilator Weaning / Q000379:methods* / Q000401:mortality
keywords: Chronic respiratory disorder; Extubation failure; Noninvasive ventilation; Weaning