So let's talk a little bit, I've given you some tools, I've run through them really fast, and I'm sorry about that, but I wanted to give you those tools. You've got the tools now, right? You've used them, but now you're ready to extubate your patient. So what do you do, right? Well, this is a problem still, about 10 to 20% of those patients that pass in our SPT are still going to have extubation failure. The problem is that puts us in, the patient at risk for poor outcomes. What we do know is if we have to re-intubate a patient, whether it's planned or unplanned, we're adding seven additional days to that patient's stay. The cost of seven additional days to an organization or to your, is high, right? To me, the bigger impact is it increases mortality. That means that patient's at higher risk, up to 50% higher risk if they have to be re-intubated. So the idea behind this is we really need to be more prophylactic in our support measures and what we're extubating the patient to. And we need to really look at where their risk is. If they're high risk, we definitely need to be thinking about being prophylactic with that. What does that mean? So that means we have lots of different strategies. We can extubate to conventional oxygen, which we've all been doing for years, right? That's nothing new. There's high flow options. There's non-invasive options and there's also combination therapies. And I've been to a few talks today that have actually talked about that a little bit more. But I think the other thing we have to look at is what put the patient on the vent to begin with? Was it a hypoxic reason or was it a hypercapnic reason? Because that might make you choose a different path here as well. So Dr. Hernandez and his team, they in 2016 actually looked at the effect of post-extubation. High flow cannula versus conventional oxygen therapy in re-intubating low risk patients. So their risk you can see are less than 65, Apache less than 12 and a BMI less than 30. Again, I'm from the Midwest. There's nobody that has a BMI less than 30 in our ICU. We like our food, myself included, but I'm not a BMI of over 30. So anyway, you have to exercise. So they randomized them to high flow or conventional oxygen. Now, when you look at a lot of these studies, I like to point this out. Conventional oxygen is usually one of two things. It's either a non-rebreather mask or it's a five liter nasal cannula. Take your pick. In this study, they just picked whichever for conventional. They didn't say 50% were going to nasal prongs, 50% were going to non-rebreather. They just had whatever they felt like for the patient or whoever the physician was or the RT or nurse wanted, that's what they put them on for conventional oxygen. And they compared them to high flow. And they looked at reintubation within 72 hours. So what you can see here is nasal high flow significantly reduced reintubation in the high flow group versus conventional oxygen. Nasal high flow significantly reduced post-extubation respiratory failure. And they successively extubated patients. The ones that got extubated to high flow had shorter durations of mechanical ventilation. That makes sense. If you're not on, you don't need to go back on, right? ICU stay dropped significantly. It went from 11 days to two days and hospital stay dropped. This is all great because this is the low risk patient. Again, I mentioned half of us don't have low risk patients. So what happens to the high risk patient? Well, this same group looked at the high risk patients. So this is a three center randomized controlled study that they looked at non-inferiority of nasal high flow compared to non-invasive. I would say that we probably are all in agreement. If we have one of these patients that's high risk, most of us are probably gonna extubate to non-invasive, right? Not all, but a lot of people do. So they randomized these patients to high flow or non-invasive for 24 hours post-extubation. And they looked at reintubation rates within 72 hours, respiratory failure, and their non-inferiority range, a margin was about 10%. And what they found was nasal high flow is non-inferior to non-invasive for rates of reintubation and post-extubation failure. So I'm gonna keep going here, but I have some thoughts behind this. ICU length of stay was lower in the nasal high flow group. No patients in the nasal high flow group experienced adverse events. Median time to reintubation was not significantly different between the two and all other outcomes were not significantly different. So in my world, when I practice as an RT, when I hear non-inferior, I'm like, it's not any worse, it's not any better. But I can never keep the mask on the patient. The patient has to have a lot of ketamine to stay in bed. The patient has to have sometimes, even though we shouldn't be doing this, we have to tie them down, right? So there's many more complications that come along with keeping a patient on non-invasive that you don't see. The other thing is, for me, I like to talk to patients. I can't hear them when they have the BiPAP mask on. They can't eat, they can't drink, they can't mobilize very well. So there's opportunities to take a look at that even in the high-risk patients. My practice or our practice was such that we would extubate to nasal high flow, even these high-risk patients, and if they failed before we went back to retubing them, we gave them a try on non-invasive. But we wanted to see how they would do with this and we found very similar information. Theo and his group, I love these guys, they're out there doing all kinds of things. Maybe someday I'll meet them. But in 2019, they did the effects of post-extubation high flow with non-invasive ventilators versus nasal high flow oxygen alone on reintubation. So they did the combo therapy. What happens if we extubate to just high flow or what if we do some time on high flow and some time on non-invasive? And so what you can see here, really they randomized them again to high flow or both. And what you can see is compared with nasal high flow standalone the use of, thank you, the use of high flow oxygen with non-invasive after extubation significantly decreased the risk of reintubation. So it's pretty close. I'm gonna keep running because we're about out of time here and I don't wanna take someone else's. I think the bigger thing is this study that they did was looking at obese patients and this is how they stratified the obese patient. And basically in obese to overweight patients at high risk for extubation failure and their post hoc analysis, really using non-invasive if they are obese or overweight, but not really using it in those that are underweight or normal weight. All right, really fast, I wanna run through some clinical practice guidelines. These were published in ATS in 2017. There's some key points here, but a few things I wanna point out is for acutely hospitalized patients ventilated more than 24 hours, their recommendation is that initial SBT should really be done on pressure support and not TPs. That's their recommendation. Minimizing sedation, using non-invasive in the high risk patients, making sure you have some sort of liberation protocol. I'm pretty sure everybody does these days, but throw that out there. And then making sure that if there's any worry about that airway, that you're doing a cuff leak check and starting steroids if you don't have an initial leak. The European Society also put together some clinical evidence as far as when to use conventional oxygen versus nasal high flow versus non-invasive ventilation. I'll kind of let you read those. The American College of Physicians also did the same thing, basically suggesting that we should use high flow, we should extubate to high flow versus conventional oxygen. And in those patients that, again, are high risk extubating them to non-invasive if you deem appropriate. And then My Passion, My Love, My AARC also published guidelines. They also published some guidelines related to where your pulse oximetry should be. So this is the guidelines that came out in 2022. Post-extubation, nasal high flow is preferred to conventional immediately post-extubation. And nasal high flow is preferred to conventional oxygen to avoid escalation to invasive or non-invasive. And with that being said, here's my references. I thank you very much. Thank you.

extubation failure

high-flow nasal cannula

non-invasive ventilation

patient outcomes

clinical guidelines