Comparing two methods of delivering high-flow gas therapy by nasal cannula following endotracheal extubation: a prospective, randomized, masked, crossover trial

Objective: We compared two methods of delivering high-flow gas therapy by nasal cannula, applied immediately after planned endotracheal extubations of NICU patients. Study design and methods: Thirty NICU patients who were about to be extubated from mechanical ventilation were randomized into two groups; Group 1 received Vapotherm(R) for the first 24 h after extubation, then standard high-flow nasal cannula for the next 24 h, and Group 2 received standard high-flow therapy for the first 24 h, then Vapotherm(R) for the next 24 h. At 24 h after extubation and again 48 h after extubation, a neonatologist who was not aware which modality the patient had been receiving examined the nasal mucosa and applied a scoring system. A research nurse who was unaware of the modality abstracted respiratory rates and respiratory effort scores from a specific study-bedside record. The experimental design was such that a patient could 'fail' extubation either by reintubation for mechanical ventilation, or by rescue to the opposite modality before completing the 24-h test period. Results: Fifteen patients were randomized to Group 1 and 15 to Group 2. No differences were apparent between the groups in birth weight, gestational age, age at study entry, gender or underlying pulmonary disorder. Respiratory rates were similar while on Vapotherm(R) (52 +/- 13 breaths/min, mean +/- s.d.) and high-flow (54 +/- 14/min). At 24 h after starting the modality, those on Vapotherm(R) had more normal examinations of the nasal mucosa (2.7 +/- 1.2 vs 7.8 +/- 1.7, P < 0.0005) and lower respiratory effort scores (1.2 +/- 0.6 vs 2.0 +/- 0.9, P < 0.05) than did those on high-flow. No patients failed while on Vapotherm(R), but seven failed while on high-flow (two reintubations and five rescue switches to Vapotherm(R), P < 0.005). Conclusions: Among NICU patients immediately following extubation, Vapotherm(R) performed better than a standard high-flow nasal cannula in maintaining a normal appearing nasal mucosa, a lower respiratory effort score, and averting reintubation.