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Critical Care

Open Access

Using noninvasive ventilation to prevent extubation failure: it is good news, but do we really know what “high risk” means?

Critical Care201620:213

Received: 29 March 2016

Accepted: 10 May 2016

Published: 4 July 2016

The original article was published in Critical Care 2016 20:48

We read with great interest the article by Thille et al. [1] and commend the authors on their work. It is accepted that noninvasive ventilation (NIV) used prophylactically reduces post-extubation respiratory failure, but its impact on reintubation remains contentious [2]. Therefore, the current study, which reports reduced rates of reintubation from 28 % to 15 % in high-risk populations with NIV use, is welcomed.

The study has several limiting factors. It is a prospective before–after study across a long time period, and the authors acknowledge this potential source of bias. There is a large gap between patient cohorts, with data from the original cohort collected between 2005 and 2006 and data from the “after” group collected between 2010 and 2012. No explanation is provided as to why this second period—4 years later—was chosen, which raises concerns regarding selection bias. Additionally, data were collected from a single centre with extensive experience of NIV use, an important factor in the success of NIV use post-extubation [3].

In mitigation, no difference between baseline reintubation rates of low-risk patients was seen between the two groups, and the second patient cohort contained fewer surgical patients—a group known to benefit from post-extubation NIV use [4].

We applaud the definition of extubation failure as reintubation within 7 days rather than 48–72 h, as we feel this provides a pragmatic view. It is likely to result in greater numbers of extubation failures and makes the findings more impressive. We also feel that an average time of NIV use of 8 h within the first 24 h represents a reproducible period for prophylactic use in critical care patients, in whom treatment compliance may be an issue.

We feel that this is an important study and welcome its contribution to the evidence pool. It does, however, raise the important question of what constitutes “high risk” of extubation failure. The authors state that NIV is “pointless” as a prophylactic measure in low-risk populations, but define over 60 % of patients included as high risk; as demands on frontline services increase this figure is surely set to rise. The emergence of high-flow nasal cannula (HFNC) therapy in patients defined as low risk of extubation failure [5] brings an even sharper focus on the need for risk stratification in all ICU patients, and further work is warranted to help guide post-extubation management.


HFNC, high-flow nasal cannula; ICU, intensive care unit; NIV, noninvasive ventilation.



Authors’ contributions

AJG and AME constructed, read, and approved the final manuscript.

Competing interests

AJG has received honoraria and speaking fees from Armstrong Medical UK between 2014 and 2016.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

Department of Critical Care, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
Intensive Care and Non Invasive Ventilatory Unit, Hospital Morales Meseguer, Murcia, Spain


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© The Author(s). 2016