Sir,
We read with interest the study by Patil et al. published in the Indian Journal of Critical Care Medicine.1 The authors are to be commended for addressing an important and evolving area in post-extubation respiratory support aimed at preventing reintubation. However, certain methodological issues and interpretative aspects merit consideration.
Firstly, the non-invasive ventilation (NIV) strategy employed passive humidification via a heat and moisture exchanger.2 Current evidence suggests that active heated humidification improves secretion clearance and patient comfort during NIV. Therefore, the NIV arm may not represent optimized standard practice, introducing a potential performance bias against NIV.
Secondly, the absence of crossover between modalities, although methodologically rigorous, does not reflect real-world intensive care unit (ICU) practice, where escalation or switching of respiratory support is often required. This is particularly relevant given that a substantial proportion of patients in the NIV group were reported to be intolerant to therapy. It would be important to know whether these patients were subsequently managed with conventional oxygen therapy or high-flow nasal cannula (HFNC), as this could have influenced outcomes and potentially magnified the observed benefit in the HFNC group. One of the major criticisms of NIV is that it delays necessary reintubation by masking signs of respiratory failure. However, this does not seem to be the case here, as the primary outcome was reintubation at 48 hours following extubation.
Thirdly, NIV has demonstrated superiority over HFNC in selected clinical conditions such as chronic obstructive pulmonary disease, acute heart failure, obesity, and hypercapnic respiratory failure.3 In the present study, more than half of the cohort appears to have had at least one such risk factor for extubation failure. This raises questions regarding the observed superiority of HFNC in a population traditionally considered to benefit more from NIV.
Finally, inclusion of patients with only a single high-risk criterion for extubation failure may have resulted in a relatively lower-risk cohort compared to prior studies, thereby limiting comparability and generalizability.
In conclusion, while the study adds valuable evidence to the ongoing debate between HFNC and NIV in post-extubation care, the conclusion regarding the superiority of HFNC should be interpreted with caution. Larger multicentre trials with standardized NIV protocols and longer follow-up are required before definitive practice change can be recommended.
Orcid
Riddhi Kundu https://orcid.org/0000-0001-6222-1974
Anirban Bhattacharjee https://orcid.org/0000-0002-7657-7450
Aayush Chawla https://orcid.org/0000-0002-9545-5299
Footnotes
Source of support: Nil
Conflict of interest: None
References
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